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Patterns of Interpreter Use for Hospitalized Patients with Limited English Proficiency

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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. Evaluate interpreter use for clinical encounters in the hospital. Cross-sectional. Hospitalized Spanish and Chinese-speaking LEP patients. Patient reported use of interpreters during hospitalization. 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). 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.
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Patterns of Interpreter Use for Hospitalized Patients
with Limited English Proficiency
Yael Schenker, MD, MAS
2
, Eliseo J. Pérez-Stable, MD
1
, Dana Nickleach, MS
1
, and Leah S. Karliner,
MD, MAS
1
1
Medical Effectiveness Research Center for Diverse Populations, Division of General Internal Medicine, Department of Medicine, University of
California, San Francisco, CA, USA;
2
Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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.
PAR TI CI PAN TS : 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 bywithout 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 morecommonwithphysicians
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 bywithout an interpreter or barely
speaking at all.
KEY WORDS: language proficiency; interpreter use; non-English-
speaking patients.
J Gen Intern Med 26(7):7127
DOI: 10.1007/s11606-010-1619-z
© Society of General Internal Medicine 2011
INTRODUCTION
The use of professional interpreters improves the quality of care for
patients with limited English proficiency (LEP), resulting in
increased patient satisfaction, reduced disparities, and improved
clinical outcomes.
13
Title VI of the Civil Rights Act mandated access
to language services for all health care organizations receiving
federalfunds,andatleast43stateshaveenactedoneormorelaws
addressing language access in healthcare settings.
4,5
In addition,
hospital guidelines, including the Joint Commission standards,
recommend the routine use of professional interpreters.
6,7
Yet professional interpreters are often not used for patients with
LEP.
8,9
Resident physicians report relying frequently on ad hoc
interpretation by family members, friends or clinical staff, or using
their own limited second language skills.
1012
These studies
suggest both inadequate access to appropriate language services
and widespread underuse of professional interpreters, but do not
illustrate how patterns of interpreter use may vary for different
types of interactions in the hospital.
13
Few studies have examined
interpreter use with nurses, and interpreter use is rarely assessed
from the patients perspective. Understanding patterns of inter-
preter use is critical to the design and implementation of effective
interventions to improve the quality of care for patients facing
language barriers in the hospital. We therefore conducted this
study to examine interpreter use for clinical encounters with
physicians and nurses among hospitalized Spanish- and Chinese-
speaking patients with LEP.
METHODS
Design and Setting
Hospitalized Spanish- and Chinese-speaking patients with
LEP were recruited as part of a larger study on hospital and
Received July 30, 2010
Revised December 13, 2010
Accepted December 15, 2010
Published online February 19, 2011
712
discharge communication. The larger study followed
patients after their hospitalizations, and included compari-
son data on English-speakers. The current cross-sectional
analysis includes baseline data on patients with LEP only.
Patients were enrolled from the general medical and
surgical wards at two urban hospitals in the San Francisco
Bay Areaone public and one academic medical center. Both
sites serve a diverse patient population: approximately 33% of
patients at the public hospital and 18% of patients at the
academic medical center speak limited English. The public
hospital employees 20 staff interpreters who work in a broad
range of languages, the most frequent of which is Spanish.
The academic medical center employs 19 staff interpreters
who work in three main languages (Chinese, Spanish,
Russian). At both medical centers, staff interpreters serve
extensive outpatient primary care and specialty clinics, busy
emergency departments, and the inpatient hospital. Both
sites are teaching hospitals and resident physicians with
faculty supervision see the majority of admissions initially.
The public hospital is a level II Trauma Center and has 236
inpatient beds. The academic medical center houses a
childrens hospital and has 600 inpatient beds.
Initial recruitment of Spanish-speaking patients took place
at the public hospital during two six-month periods between
2005 and 2007. In order to increase the diversity of our
sample, in 20072008 we recruited Chinese-speaking (both
Mandarin and Cantonese) patients at both the public hospital
and the academic medical center, which has a larger Chinese
population.
At both sites, Chinese- and Spanish-speaking in-person
professional interpreters were available weekdays from 8 AM
5 PM throughout the recruitment period. Both hospitals also
had between one and three speaker or dual-handset phones
available on each medical and surgical ward. These tele-
phones could be used to access professional interpreters 24-
hours-per day, 7 days per week. In addition, the public
hospital employed two nurses with the dual role of working
as Spanish interpreters when they were on the medical
surgical floor.
Participant Eligibility and Recruitment
Participant eligibility criteria for the larger study on hospital
and discharge communication included 1) admission to the
general medical or surgical ward; 2)18 years old; 3) Chinese-,
Spanish- or English-speaking; and 4) able to pass a brief
cognitive screening test, to ensure that the participant was
cognitively intact in order to complete the interview
14
. Recruit-
ment was conducted by bilingual research assistants who
visited the hospital wards three times per week. After reviewing
chart documentation of the patients primary language and
checking with the charge or floor nurse for permission to enter
the patients room, the research assistant approached all
available Spanish- and Chinese-speaking patients for potential
participation. English-speaking patients were also recruited
over the same time period for the larger study, but only
patients with LEP were included in this analysis. The informed
consent process and baseline interview were conducted in the
patients preferred language during his or her hospitalization,
on average 3 (±3) days after admission. Participants received
$15 after the baseline interview in appreciation of their time
and effort. The institutional review boards at each hospital
approved all study procedures.
Measures
English proficiency was determined by asking patients how
well they spoke English (not at all,’‘not well,’‘wellor very
well) and in what language they preferred to receive their
medical care. Based on previous work
15
, patients who reported
speaking English not at allor not well,and patients who
reported speaking English wellbut preferring to receive
medical care in another language were designated as limited
English proficient.
Patients were asked about their use of interpreters for three
types of clinical encounters: with the physician at admission,
with physicians since admission, and with nurses since
admission. For each encounter, patients were reminded that
an interpreter could be a family member or friend, a hospital
staff member, or a professional provided by the hospital
specifically to interpret. If the patient reported that any type
of interpreter was present, they were prompted to indicate who
did most of the interpreting for that type of clinical encounter.
If the patient reported that an interpreter was not present, they
were asked why they didnt use an interpreter (see Fig. 1).
In addition, patients were asked about their preferences for
interpreter use with physicians (In general, do you prefer to
have someone interpret for you when you speak with a
physician?) and with nurses (In general, do you prefer to
have someone interpret for you when you speak with a
nurse?), as well as their overall access to interpreters in the
hospital (Since being in the hospital, has anybody ever asked
you if you wanted or needed an interpreter?).
Age and sex were determined by questionnaire. Education
was measured by asking participants What is the highest
grade or year of school you have completed?Co-morbidity
score was measured using an adaptation of the validated Self-
Administered Co-morbidity Questionnaire
16
,whichwas
designed for use in clinical and health services survey
research, using a count of co-morbidities with a potential
range of 0-15. The hospital service (Medicine or Surgery) caring
for each patient was determined from the medical record.
Data Analysis
Our goal was to examine patterns of interpreter use for the
three different types of clinical encounters (with the physician
at admission, with physicians since admission, and with
nurses since admission). In bivariate analysis, we compared
presence of an interpreter for each encounter type by patient
characteristics using Pearson chi-square tests. We then com-
pared type of interpreter present and reasons why an inter-
preter was not present by clinical encounter type using Rao-
Scott chi-square tests to adjust for patient clusters given that
patients were asked the same questions three times about
three different encounter types. Finally, we used logistic
regression to explore predictors of interpreter use for the three
encounter types, adjusting for patient characteristics hypoth-
esized a priori to be associated with interpreter use (age, sex,
713Schenker et al.: Interpreter Use in the HospitalJGIM
education, primary language, co-morbidity score and hospital
service).
RESULTS
A total of 374 patients were recruited in the overall study
between 2005 and 2008, with a collaboration rate of 71%. For
this cross-sectional analysis, we included only Spanish- and
Chinese-speaking patients with limited English proficiency (N
=234). Of the 234 participants, 54% were men, 22% had
completed high school, and the mean age was 44 years (range
18 to 88). Participants were 85% Spanish-speaking and 15%
Cantonese- or Mandarin-speaking. The mean number of co-
morbidities was 1.9 (s.d. 1.7; range 0 to 8). Overall, 39% of
participants were hospitalized on a medical service and 61%
were hospitalized on a surgical service. Most (78%) reported
that they were first seen by a physician in the Emergency
Department.
The vast majority (93%) of participants reported a general
preference for interpreters when speaking with physicians;
most (73%) also preferred interpreters when speaking with
nurses. However, only 43% of all participants reported that
they had been asked if they wanted or needed an interpreter
since admission. Overall, 130 (57%) of participants reported
that any type of interpreter was present with the physician at
admission, 137 (60%) reported that any type of interpreter was
ever used with physicians since admission, and 85 (37%)
reported that any type of interpreter was ever used with nurses
since admission.
Table 1shows whether an interpreter was present for each
of the three clinical encounter types, by patient characteristics.
With both physicians and nurses, interpreter use was more
common in encounters with older patients and with Chinese-
speaking patients. Interpreter use was also somewhat more
common with patients with more co-morbidity. During hospi-
talization, use of interpreters with nurses was more common
for communication with less educated patients, and with both
physicians and nurses interpreter use was more common for
patients on a Medical service.
Patterns of interpreter use for each clinical encounter type
are shown in Table 2. The use of hospital interpreters was
uncommon overall (17% with physician at admission, 14%
with physicians since admission), but particularly infrequent
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). Use of a nurse,
clerk or another physician as interpreter was more common
with physicians since admission (23%) as compared to with
physicians at admission (12%) or with nurses (14%; p=
0.0004). Few patients reported that they did not use an
interpreter because physicians spoke their language well
(19% at admission, 12% since admission) and even fewer
reported non-use because nurses spoke their language well
(6%; p= 0.0001). Patients were more likely to report that they
either got bywith a little English or were barely spoken to at
all with nurses (38%) than with physicians at admission (14%)
or since admission (15%; p< 0.0001).
We present multivariate results in Table 3. Older age was
associated with higher odds of interpreter use with the
physician at admission (OR 1.4, 95% CI 1.1-1.8; p=0.001),
When you came to the
hospital and were first seen by
a physician did you use an
interpreter?
YES NO
Physician at Admission Physicians since Admission Nurses since Admission
Since being in the hospital,
has anyone ever interpreted
for you when you spoke with
the physicians?
Since being in the hospital,
has anyone ever interpreted
for you when you spoke with
the nurses?
Who did most of the interpreting? Why didn’t you use an interpreter?
Hospital/professional interpreter in person
or by telephone
Family member or friend
Another patient
A nurse or clerk who is not a professional
interpreter
Another physician who speaks your
language
Preferred to speak English
The physician/nurse spoke your native
language well
It took too long to wait for an interpreter
There was no interpreter available
“Gotby” with a little English
The physician/nurse barely spoke to you
at all
Figure 1. Questions and response options regarding use of interpreters for three types of clinical encounters.
714 Schenker et al.: Interpreter Use in the Hospital JGIM
but this association did not achieve significance for other
encounter types. Patient primary language was not associated
with interpreter use with physicians, but Chinese-speaking
patients had higher odds than Spanish-speakers of interpreter
use with nurses (OR 3.3, 95% CI 1.2-9.3; p=0.02). Compared
to a surgical service, hospitalization on a medical service was
associated with higher odds of interpreter use for encounters
with both physicians (OR 2.1, 95% CI 1.1-3.9; p=0.02) and
nurses (OR 2.6, 95% CI 1.4-4.8; p=0.003) since admission,
but not with physicians at admission.
DISCUSSION
We report here on a unique study of patterns of interpreter use
in the hospital from the patient perspective. Among hospital-
ized Spanish- and Chinese-speaking patients with LEP at two
clinical sites, we found that interpreter use varied for clinical
contacts with physicians or nurses, but was low overall.
Hospital or professional interpreters were infrequently used
for any type of contact, yet few patients reported that
physicians or nurses spoke their native language well. With
physicians, use of family, friends or staff as ad hoc interpreters
was most common; in contrast, with nurses, patients often
reported getting bywithout an interpreter or barely speaking
at all. The low rates of reported professional interpreter use
during three categories of interactions with both physicians
and nurses raise concerns about quality of care for hospital-
ized patients with LEP.
Our findings of low rates ofprofessional interpreter use overall
mirror the results of studies conducted in the emergency
department
8
and outpatient settings.
17
In exploring patient
characteristics associated with patterns of interpreter use, we
found that patients hospitalized on a medical service reported
higher rates of interpreter use for encounters with physicians
and nurses than patients hospitalization on a surgical service.
This result suggests that different specialties may have very
different patterns of communication with hospitalized patients.
Further research is needed to examine this hypothesis and its
implications in broader populations and settings.
Table 1. Presence of Interpreters at Three Types of Clinical Encounters by Patient Characteristics (N= 234), at Two Hospitals in the San
Francisco Bay Area, 20052008
N Interpreter present
with physician
at admission N (%)
P value Interpreter present
with physicians
since admission N (%)
P value Interpreter present
with nurses
since admission N (%)
P value
Age 0.0001 0.03 0.003
18-24 28 11 (39) 16 (57) 8 (29)
25-49 128 61 (48) 68 (54) 37 (29)
50-64 46 33 (77) 27 (66) 21 (49)
65 32 25 (78) 26 (81) 19 (59)
Sex 0.28 0.95 1.0
Men 126 66 (53) 74 (60) 46 (37)
Women 108 64 (60) 63 (61) 39 (37)
Education 0.58 0.19 0.03
Less than High School graduate 183 104 (57) 112 (63) 73 (40)
High School graduate or more 51 26 (53) 25 (52) 12 (24)
Primary language 0.002 0.03 <0.0001
Cantonese/Mandarin 35 25 (78) 22 (69)
Spanish 199 112 (57) 63 (32)
Co-morbidity Score 0.04 0.17 0.02
0 56 24 (43) 28 (51) 13 (23)
1 62 33 (53) 40 (66) 26 (41)
2 38 23 (61) 20 (53) 11 (29)
3 or more 74 50 (68) 49 (67) 35 (47)
104 (53)
Hospital Service 0.95 0.004 0.0002
Medical 90 50 (57) 63 (72) 46 (52)
Surgical/Gyn 142 79 (56) 73 (53) 39 (28)
Table 2. Patterns of Interpreter use for Three Types of Clinical
Encounters Among Patients (N=234) at Two Hospitals in the San
Francisco Bay Area, 2005-2008
With
physician
at admission
N (%)
With
physicians
since
admission
N (%)
With nurses
since
admission
N (%)
Interpreter present 130 (57) 137 (60) 85 (37)
Hospital interpreter 37 (17) 30 (14) 10 (4)
Family member,
friend or other
patient
63 (28) 50 (23) 42 (18)
Nurse, clerk or
physician
26 (12) 52 (23) 31 (14)
Interpreter not
present
100 (43) 90 (40) 146 (63)
Preferred to speak
English
10 (4) 13 (6) 20 (9)
Physician or nurse
spoke your native
language well
42 (19) 26 (12) 14 (6)
Too long to wait or
none available
15 (7) 17 (8) 26 (11)
Got byor the
physician/nurse
barely spoke to
you at all
31 (14) 34 (15) 86 (38)
715Schenker et al.: Interpreter Use in the HospitalJGIM
The particularly low rate of interpreter use we observed in
encounters with nurses is striking and has not been previously
described. While interactions with nurses may be shorter and
more routine than interactions with physicians, they frequently
involve critical communication such as assessing a patients
pain level or checking for medication allergies. Getting by
without language assistance for these encounters may nega-
tively impact the care of patients with LEP, and could have
significant clinical consequences.
18,19
Interestingly, patient pref-
erence for interpreter use, while slightly lower for interactions
with nurses than for interactions with doctors, was high overall.
Failure to use any type of interpreter for nursing encounters
thus seems unlikely to represent a patient-centered decision.
Several possible explanations exist for our findings of infre-
quent interpreter use among nurses. It is possible that nurses
are getting bywithout interpreters because they view commu-
nication as a less critical part of many of their routine
interactions with patients. For example, when giving a medica-
tion or changing a patients dressing, a nurse may not think an
interpreter is necessary. However, our finding that only 37% of
patients reported ever using an interpreter when speaking with
a nurse suggests that language service use is uncommon for
more complex as well routine nursing interactions. It is also
possible that nurses do not receive adequate training regarding
how to access interpreter services, or that patients do not realize
that they are entitled to an interpreter when talking with nurses.
Finally, it is likely that current models of interpreter delivery
present a greater challenge for nurses than for physicians. While
physicians have more flexibility in their days and can schedule
an in-person professional interpreter in advance, or return to
see a patient at a later time when an interpreter is available,
nurses are constantly moving from one task to the next and can
seldom delay patient care activities to wait for language
assistance.
Several recommendations stem from these findings. First,
innovations are needed to improve access to professional
interpreters for hospitalized patients with LEP. The acute
hospital setting presents a particularly difficult access challenge
due to the 24-hour nature of care, time pressures, and the
brevity of many interactions. Attention should be paid to the
types of hospital interactions for which remote modalities of
professional interpretationsuch as telephonic and video-con-
ferencing interpretationare adequate, and those for which an
in-person professional interpreter is required. When studied at a
different public hospital, video medical interpretation (VMI)
with interpreters housed at a central call centerhas been
shown to decrease costs per interpreted encounter and increase
the volume of interpretation provided per month.
20
While VMI
exists in other locations at both the medical centers in our
study, it has not yet been successfully integrated into an adult
inpatient setting at any hospital. Further implementation of VMI
and telephonic interpretation with easy access at the bedside
may increase utilization by both nurses and physicians in the
busy inpatient setting. Second, hospitals can assist with the
appropriate allocation of available resources by setting and
enforcing standards for appropriate interpreter use, as well as
improving systems to identify and flag patients who speak
limited English (much the way hospitals identify patients who
are a fall risk). Third, patients should also be better educated
about their right to a professional interpreter, as sometimes it
may be only the patient who realizes that an interpreter is
necessary.
13
Lastly, more research is needed to better define the
impact of interpreter use on errors and costs. We postulate that
failure to communicate adequately with patients with LEP may
contribute to medical errors during hospitalization
21
,aswellas
higher rates of re-hospitalization compared with English-speak-
ing patients.
22
While cost is clearly a barrier to achieving
adequate interpreter access
4
, such costs may be offset by
avoiding significant errors and unnecessary re-hospitalizations.
Several limitations must be considered in the interpretation of
our study. First, this was a study at two sites; our findings may
not generalize to other hospitals or settings. However, both sites
in this study serve large numbers of patients with LEP and are
located in a diverse area of the US. It is likely that patients
experiences may be worse in settings with less linguistic diversity
or resources allocated to interpreter services. Second, available
patient populations and our recruitment methods resulted in all
Spanish-speaking patients being enrolled at the public hospital
and the majority of Chinese-speaking patients being enrolled at
the academic medical center. We were therefore unable to
Table 3. Predictors of Interpreter use for Three Types of Clinical Encounters* Among Patients (N=234) at Two Hospitals in The San Francisco Bay
Area, 2005-2008
With physician at admission With physicians since
admission
With nurses since admission
MV Adjusted
OR (95% CI)
P value MV Adjusted
OR (95% CI)
P value MV Adjusted
OR (95% CI)
P value
Age (per 10-year increase) 1.4 (1.1-1.8) 0.001 1.2 (0.9-1.4) 0.14 1.2 (1.0-1.5) 0.10
Sex 0.61 0.87 0.90
Men 0.9 (0.5-1.5) 1.0 (0.5-1.7) 1.0 (0.5-1.8)
Women Ref Ref Ref
Education 1.0 .30 0.05
Less than High School graduate 1.0 (0.5-2.0) 1.4 (0.7-2.8) 2.2 (1.0-4.9)
High School graduate or more Ref Ref Ref
Primary language 0.44 0.30 0.02
Cantonese/Mandarin 1.5 (0.5-4.6) 1.8 (0.6-5.1) 3.3 (1.2-9.3)
Spanish Ref Ref Ref
Medical co-morbidity score (per 1-pt increase) 1.0 (0.9-1.3) 0.64 0.9 (0.8-1.1) 0.51 0.9 (0.8-1.1) 0.41
Hospital Service 0.25 0.02 0.003
Medicine 0.7 (0.4-1.3) 2.1 (1.1-3.9) 2.6 (1.4-4.8)
Surgical Ref Ref Ref
*All odds ratios for a model adjusted for age, sex, education, primary language, medical co-morbidity score and hospital service
716 Schenker et al.: Interpreter Use in the Hospital JGIM
examine or adjust for site differences, and it is possible that
differences in interpreter use by language reflect unmeasured
differences between the two sites. In fact, we enrolled more
surgical than medical patients, possibly reflecting the fact that
the public hospital site serves a relatively young population
hospitalized for acute illness or trauma. Additionally, we included
only Spanish- and Chinese-speaking patients (the two most
common non-English languages spoken at these hospitals and
in the US), and our sample was not evenly balanced between the
two. It is possible that the experiences of patients who speak
other, less common languages may be quite different, but seems
unlikely to be better than reported here. Third, we captured data
on general interaction types for both medical and surgical patients,
and do not have information on the clinical content or frequency of
these encounters. Specific communication needs on medical and
surgical services may be quite different, and could not be examined
as part of this study. And finally, interpreter use was based on
patient self-report, and not directly observed, nor were interpreter
records reviewed or physicians and nurses surveyed.
Overall, our findings suggest that interpreter use for hospital-
ized patients with LEP is inadequate. Interventions are needed to
improve the interpreter use for the frequent and often brief
interactions between hospitalized patients with LEP and their
clinicians. Increasing access to professional interpreters, priori-
tizing encounter types for which interpreters should be used,
educating physicians, nurses and patients about language
services, and changing organizational and professional norms
around communication with hospitalized patients may signifi-
cantly improve the quality and safety of care provided to
hospitalized patients with LEP.
Acknowledgements: This study was supported by grant no.
20061003 from The California Endowment and by grant no. P30-
AG15272 of the Resource Centers for Minority Aging Research
program funded by the National Institute on Aging, National
Institutes of Health. Dr. Schenker was supported by the General
Internal Medicine Fellowship at UCSF, funded by the Department of
Health and Human Services, Health Resources and Services
Administration (DHHS HRSA D55HP05165), and then by a Junior
Faculty Career Development Award from the National Palliative Care
Research Center. We thank Steven Gregorich for statistical advice,
Gabriel Somma, Monica Lopez and Julissa Saavedra for data
collection and management, and the staff and physicians at the
Alameda County Medical Center for their participation.
Conflict of Interest: None disclosed.
Corresponding Author: Eliseo J. Pérez-Stable, MD; Medical
Effectiveness Research Center for Diverse Populations, Division of
General Internal Medicine, Department of Medicine, University of
California, 0856, 3333, California Street, San Francisco, CA 94143
085, USA (e-mail: eliseops@medicine.ucsf.edu).
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717Schenker et al.: Interpreter Use in the HospitalJGIM
... Up to 14% reported that physicians attempted to communicate without an interpreter. 9 However, professional interpreters have been shown to make significantly fewer mistakes compared to ad hoc interpreters or physicians with no interpreter at all. An analysis of audio-taped emergency department visits in Massachusetts demonstrated that the proportion of errors which were potentially clinically significant was higher with no interpreter (20%) and ad-hoc interpreters (22%) compared to with a professional interpreter (12%, p<0.01). ...
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Limited English proficiency (LEP) affects many Canadians. Patients with LEP are at high risk of medical error, readmission, and increased length of stay. We report on the case of a 66-year-old male with LEP and a diag-nosis of glucose-6-phosphate dehydrogenase (G6PD) deficiency associated hemolysis, and how the language barrier affected his care. Using our case as an example, we describe trends in the LEP literature in the inpa-tient setting, its effects on patient care and the evidence surrounding the use of point of care interpretation.
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Clear and effective communication is vital to quality patient care. More than 66 million Americans (21.5%) speak a language other than English at home, with more than 25 million (8.2%) speaking English "less than very well." Addressing language differences in the orofacial pain setting is of utmost importance to care quality, treatment outcomes, and overall health equity. In the case presented, language-related communication challenges affect the diagnosis and management of a patient with orofacial pain. This case highlights the significance of language discordance in the clinical setting and demonstrates the need for greater language access in the orofacial pain field.
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This systematic review assesses whether limited-English proficiency (LEP) increases risk of having poor perioperative care and outcomes. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 99 articles were identified in Embase and PubMed and screened by 2 independent reviewers. Ten studies, which included 3 prospective cohort studies, 6 retrospective cohort studies, and 1 cross-sectional study, met inclusion and exclusion criteria. All studies were of high-quality rating according to the Newcastle-Ottawa scale. Subsequently, the Levels of Evidence Rating Scale for Prognostic/Risk Studies and Grade Practice Recommendations from the American Society of Plastic Surgeons were used to assess the quality of evidence of each study and the strength of the body of evidence, respectively. There is strong evidence that professional medical interpreter (PMI) use or having a language-concordant provider for LEP patients improves understanding of the procedural consent. The evidence also highly suggests that LEP patients are at risk of poorer postoperative pain control and poorer understanding of discharge instructions compared with English-speaking patients. Further studies are needed to discern whether consistent PMI use can minimize the disparities in pain control and discharge planning between LEP and English-proficient (EP) patients. There is some evidence that LEP status is not associated with differences in having adequate access to and receiving surgical preoperative evaluation. However, the evidence is weak given the small number of studies available. There are currently no studies on whether LEP status impacts access to preoperative evaluation by an anesthesiology-led team to optimize the patient for surgery. There is some evidence to suggest that LEP patients, especially when PMI services are not used consistently, are at risk for increased length of stay, more complications, and worse clinical outcomes. The available outcomes research is limited by the relative infrequency of complications. Additionally, only 4 studies validated whether LEP patients utilized a PMI. Future studies should use larger sample sizes and ascertain whether LEP patients utilized a PMI, and the effect of PMI use on outcomes.
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Purpose Professional interpreters can improve healthcare quality and outcomes when there is language discordance between patients and health care providers. Multidisciplinary rehabilitation relies on nuanced communication; however, the use of interpreters in rehabilitation is underexplored. This study aimed to examine patterns of health care interpreter use in an inpatient rehabilitation setting. Methods A retrospective cohort study was conducted including patients admitted for subacute rehabilitation during 2019–2020 identified as having limited English proficiency. Patterns of interpreter use (professional and “ad hoc”) and rehabilitation outcomes were evaluated via medical record review. Results Eighty-five participants were included. During inpatient rehabilitation (median 17 [12–28] days), most clinical interactions (95%) occurred without an interpreter present. Patterns of interpreter use were variable; with greater use of ad hoc versus professional interpreters (received by 60% versus 49% of the cohort, respectively). Those who interacted with a professional interpreter had a longer length-of-stay, larger Functional Independence Measure (FIM) gain, and lower rate of hospital readmission six months post-discharge. The number of professional interpreter sessions correlated positively with FIM gain. Conclusions Access to professional interpreters in inpatient rehabilitation was variable, with some patients having no or minimal access. These findings provide preliminary evidence that professional interpreter use may be associated with clinical rehabilitation outcomes. • Implications for rehabilitation • Professional health care interpreters can be used to overcome language barriers in rehabilitation. • In an inpatient rehabilitation setting, professional interpreters appeared to be underutilized, with many patients having no or minimal access to interpreters. • Use of ad hoc, untrained interpreters and informal communication strategies was common during rehabilitation. • Use of professional interpreters appeared to be associated with favorable rehabilitation outcomes.
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Background: There are approximately 25.6 million individuals with limited English proficiency (LEP) in the USA, and this number is increasing. Objective: Investigate associations between LEP and access to care in adults. Design: Cross-sectional nationally representative survey. Participants: Adults with (n = 18,908) and without (n = 98,060) LEP aged ≥ 18 years identified from the 2014-2018 Medical Expenditure Panel Survey MAIN MEASURES: Associations between LEP and access to healthcare and preventive services were evaluated with multivariable logistic regression models, stratified by age group (18-64 and ≥ 65 years). The official government definition of LEP (answers "not at all/not well/well" to the question "How well do you speak English?") was used. Access to care included having a usual source of care (and if so, distance from usual source of care, difficulty contacting usual source of care, and provision of extended hours), visiting a medical provider in the past 12 months, having to forego or delay care, and having trouble paying for medical bills. Preventive services included blood pressure and cholesterol check, flu vaccination, and cancer screening. Key results: Adults aged 18-64 years with LEP were significantly more likely to lack a usual source of care (adjusted odds ratios [aOR] = 2.48; 95% confidence interval [CI] = 2.27-2.70), not have visited a medical provider (aOR = 2.02; CI = 1.89-2.16), and to be overdue for receipt of preventive services, including blood pressure check (aOR = 2.00; CI = 1.79-2.23), cholesterol check (aOR = 1.22; CI = 1.03-1.44), and colorectal cancer screening (aOR = 1.58; CI = 1.37-1.83) than adults without LEP. Results were similar among adults aged ≥ 65 years. Conclusions: Adults with LEP had consistently worse access to care than adults without LEP. System-level interventions, such as expanding access to health insurance coverage, providing language services, improving provider training in cultural competence, and increasing diversity in the medical workforce may minimize barriers and improve equity in access to care.
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Provision of language services is central to the delivery of equitable, safe, high-quality health care for patients with limited English proficiency. However, there are many barriers to ensuring access to such services. We analyzed the experience of a model language service program at a public hospital to develop recommendations applicable to all hospitals that wish to create an effective language service program. Our case study demonstrates that with organizational commitment, early information technology involvement, attention to clinical needs, active engagement of stakeholders, and coordinated project management, it is possible to provide high-quality language services in a setting of financial constraints.
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Language barriers complicate physician-patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood. To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP). Qualitative study using in-depth interviews. Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services. An interview guide was used to explore decision making about interpreter use. Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as "getting by;" 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician's use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care. Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to "get by" without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.
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Objective. To examine differences in the characteristics of adverse events between English speaking patients and patients with limited English proficiency in US hospitals. Setting. Six joint Commission accredited hospitals in the USA. Method. Adverse event data on English speaking patients and patients with limited English proficiency were collected from six hospitals over 7 months in 2005 and classified using the National Quality Forum endorsed Patient Safety Event Taxonomy. Results. About 49.1% of limited English proficient patient adverse events involved some physical harm whereas only 29.5% of adverse events for patients who speak English resulted in physical harm. Of those adverse events resulting in physical harm, 46.8% of the limited English proficient patient adverse events had a level of harm ranging from moderate temporary barm to death, compared with 24.4% of English speaking patient adverse events. The adverse events that occurred to limited English proficient patients were also more likely to be the result of communication errors (52.4%) than adverse events for English speaking patients (35.9%). Conclusions. Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient-provider encounter.
Article
Objective. To describe perceptions of how a lack of house staff Spanish proficiency adversely affects communication with Spanish-speaking families with limited English proficiency (LEP). Methods. An anonymous, structured questionnaire was administered to the house staff an of urban, university-affiliated children's hospital that serves a population in which 10%-20% have LEP. Results. Ninety-four percent (59 of 63) completed the questionnaire. Sixty-eight percent (40 of 59) reported that they spoke little or no Spanish (although 36 of 40 expressed a desire to learn Spanish). Fifty-three percent (21 of 40) of these nonproficient residents reported that they used their inadequate language skills in the care of patients "often" or "every day." Many of these residents believed that LEP families under their care "never" or only "sometimes" understood their child's diagnosis (21 of 40), medications (11 of 40), discharge instructions (17 of 40), or follow-up plan (16 of 40). Eighty percent (32 of 40) admitted to avoiding communication with such families. Although all (40 of 40) agreed that hospital interpreters were effective, 30 of 40 nonproficient residents reported use of hospital interpreters "never" or only "sometimes." Fifty-three percent (21 of 40) of these nonproficient residents reported calling on their proficient colleagues "often" or "every day" for assistance. Thirty-two percent (19 of 59) of residents described themselves as "fluent" or "proficient" in Spanish. Fifty-eight percent (11 of 19) reported that they were asked to interpret for fellow residents "often" or "every day." Proficient residents estimated that they spent a mean of 2.3 hours per week interpreting for other residents. Conclusions. Despite a perception that they are providing suboptimal communication, nonproficient residents rarely use professional interpreters. Instead, they tend to rely on their own inadequate language skills, impose on their proficient colleagues, or avoid communication with Spanish-speaking families with LEP.
Article
OBJECTIVE: To determine whether professional interpreter services increase the delivery of health care to limited-English-proficient patients. DESIGN: Two-year retrospective cohort study during which professional interpreter services for Portuguese and Spanish-speaking patients were instituted between years one and two. Preventive and clinical service information was extracted from computerized medical records. SETTING: A large HMO in New England. PARTICIPANTS: A total of 4,380 adults continuously enrolled in a staff model health maintenance organization for the two years of the study, who either used the comprehensive interpreter services (interpreter service group [ISG]; N=327) or were randomly selected into a 10% comparison group of all other eligible adults (comparison group [CG]; N=4,053). MEASUREMENTS AND MAIN RESULTS: The measures were change in receipt of clinical services and preventive service use. Clinical service use and receipt of preventive services increased in both groups from year one to year two. Clinical service use increased significantly in the ISG compared to the CG for office visits (1.80 vs 0.70; P<.01), prescriptions written (1.76 vs 0.53; P<.01), and prescriptions filled (2.33 vs 0.86; P<.01). Rectal examinations increased significantly more in the ISG compared to the CG (0.26 vs 0.02; P=.05) and disparities in rates of fecal occult blood testing, rectal exams, and flu immunization between Portuguese and Spanish-speaking patients and a comparison group were significantly reduced after the implementation of professional interpreter services. CONCLUSION: Professional interpreter services can increase delivery of health care to limited-English-speaking patients.
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Few studies have examined whether patients with language barriers receive worse hospital care in terms of quality or efficiency. : To examine whether patients' primary language influences hospital outcomes. Observational cohort of urban university hospital general medical admissions between July 1, 2001 to June 30, 2003. Eighteen years old or older whose hospital data included information on their primary language, specifically English, Russian, Spanish or Chinese. Hospital costs, length of stay (LOS), and odds for 30-day readmission or 30-day mortality. Of 7023 admitted patients, 84% spoke English, 8% spoke Chinese, 4% Russian and 4% Spanish. In multivariable models, non-English and English speakers had statistically similar total cost, LOS, and odds for mortality. However, non-English speakers had higher adjusted odds of readmission (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.0-1.7). Higher odds for readmission persisted for Chinese and Spanish speakers when compared to all English speakers (OR, 1.7; 95% CI, 1.2-2.3 and OR, 1.5; 95% CI, 1.0-2.3 respectively). After accounting for socioeconomic variables and comorbidities, non-English speaking Latino and Chinese patients have higher risk for readmission. Whether language barriers produce differences in readmission or are a marker for less access to post-hospital care remains unclear. Journal of Hospital Medicine 2010;5:276-282. (c) 2010 Society of Hospital Medicine.
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The proportion of the U.S. population with limited English proficiency is growing. Physicians often find themselves caring for patients with limited English proficiency in settings with limited language services. There has been little exploration of the decisions physicians face when providing care across language barriers. The authors offer a conceptual framework to aid physicians in thinking through difficult choices about language services and provide responses to common questions encountered in the care of patients with limited English proficiency. Specifically, they describe 4 factors that should inform the decision to call an interpreter (the clinical situation, degree of language gap, available resources, and patient preference), discuss who may be an appropriate interpreter, and offer strategies for when a professional interpreter is not available. The authors use a hypothetical case to illustrate how decisions about language services may evolve over the course of an interaction. This conceptual and practical approach can help clinicians to improve the quality of care provided to patients with limited English proficiency.
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To determine how often interpreters were used for Spanish- speaking patients, patients' perceived need for an interpreter, and the impact of interpreter use on patients' subjective and objective knowledge of their diagnosis and treatment. Cross-sectional survey. Public hospital emergency department. A total of 467 native Spanish-speaking and 63 English-speaking Latino patients presenting with nonurgent medical problems. Patients' report of whether an interpreter was used, whether one was needed, self-perceived understanding of diagnosis and treatment, and objective knowledge of discharge instructions. An interpreter was used for 26% of Spanish-speaking patients. For 52%, and interpreter was not used but was not thought to be necessary by the patient. A total of 22% said an interpreter was not used but should have been used. When both the patient's English and the examiner's Spanish were poor, an interpreter was not called 34% of the time, and 87% of the patients who did not have an interpreter thought one should have been used. Nurses and physicians interpreted most frequently (49%), and professional interpreters were used for only 12% of patients. Patients who said an interpreter was not necessary rated their understanding of their disease as good to excellent 67% of the time, compared with 57% of those who used an interpreter and 38% of those who thought an interpreter should have been used (P<.001). For understanding of treatment, the figures were 86%, 82%, and 58%, respectively (P<.001). However, when objective measures of understanding diagnosis and treatment were used, the differences between these groups were smaller and generally not statistically significant. There were no differences between English-speaking Latinos and native Spanish-speakers who said they did not need an interpreter. Interpreters are often not used despite a perceived need by patients, and the interpreters who are used usually lack formal training in this skill. Language concordance and interpreter use greatly affected patients' perceived understanding of their disease, but a high proportion of patients in all groups had poor knowledge of their diagnosis and recommended treatment.
Article
Many patients have limited English proficiency and require an interpreter. The authors evaluated the effect of current interpreting practices on Spanish-speaking patients' satisfaction with the patient-provider relationship. A cross-sectional survey was conducted of 457 patients seen in a public hospital emergency department. Measures were satisfaction with the provider's friendliness, respectfulness, concern, ability to make the patient comfortable, and time spent for the exam. A total of 237 patients communicated adequately with their provider without the use of an interpreter (group 1), 120 patients communicated through an interpreter (88% of whom were ad hoc interpreters; group 2), and 100 patients communicated directly with the provider but said an interpreter should have been called (group 3). Compared with patients in group 1, patients who communicated through an interpreter (group 2) rated their provider as less friendly, less respectful, less concerned for the patient as a person, and less likely to make the patient comfortable. Patients who said an interpreter should have been called (group 3) had the lowest satisfaction ratings; compared with group 2, they were less satisfied with their provider's friendliness, concern for the patient as a person, efforts to make the patient comfortable, and amount of time spent. Patients who communicated through an interpreter or who did not have an interpreter when they thought one was necessary were less satisfied with the patient-provider relationship. Further efforts are needed to ensure interpreter availability and proper interpretation technique.
Article
To develop the Self-Administered Comorbidity Questionnaire (SCQ) and assess its psychometric properties, including the predictive validity of the instrument, as reflected by its association with health status and health care utilization after 1 year. A cross-sectional comparison of the SCQ with a standard, chart abstraction-based measure (Charlson Index) was conducted on 170 inpatients from medical and surgical care units. The association of the SCQ with the chart-based comorbidity instrument and health status (short form 36) was evaluated cross sectionally. The association between these measures and health status and resource utilization was assessed after 1 year. The Spearman correlation coefficient for the association between the SCQ and the Charlson Index was 0.32. After restricting each measure to include only comparable items, the correlation between measures was stronger (Spearman r = 0.55). The SCQ had modest associations with measures of resource utilization during the index admission, and with health status and resource utilization after 1 year. The SCQ has modest correlations with a widely used medical record-based comorbidity instrument, and with subsequent health status and utilization. This new measure represents an efficient method to assess comorbid conditions in clinical and health services research. It will be particularly useful in settings where medical records are unavailable.