By Alvaro Vargas, MD
Peer Reviewed
It is not uncommon to struggle to speak to patients in the ICU, but this time it was not because my patient was intubated or sedated — we simply spoke different languages. After a 15-minute telephone adventure trying to connect with a Shanghainese interpreter, I interviewed and examined Ms. M through a Cantonese interpreter talking to her son who spoke both Cantonese and Shanghainese. Although sometimes cumbersome, there are legal [1][2] and ethical [3] obligations to invest our time and resources in such an encounter. But luckily, there is also data to support it.
Based on the most recent U.S. Census Bureau data, there are about 25 million people in the U.S. who report speaking English “less than very well” and have (by definition) limited English proficiency (LEP) [4]. There is evidence suggesting that LEP patients experience worse clinical outcomes in the inpatient setting compared to English-proficient (EP) patients; they appear to have more significant adverse events [5], longer lengths of stay (LOS) [6], and more readmissions within 30 days [7]. And while much more data is needed to show professional interpreters can bridge the gap, a recent study by Karlinger and colleagues is particularly revealing [8].
In this natural experiment, all the beds of several general medicine inpatient units were equipped with interpreter phones. LOS and 30-day readmissions were compared pre-intervention (a few phones per unit), during intervention (a phone at each bed), and post-intervention (again, a few phones per unit). After analysis of 8077 discharges, of which 1963 were LEP patients, researchers found that pre-intervention, LEP and EP patients had similar 30-day readmission rates (17.8% vs. 16.7%; OR 1.07 [CI 0.85–1.35]) but during the 8-month intervention, readmissions in the LEP were significantly lower compared to EP patients (13.4% vs. 19.7%; OR 0.64 [CI 0.43–0.95]). Post-intervention, when interpretation availability was back to baseline, the effect was lost and both groups had similar readmission rates (20.3% vs. 17.6%; OR 1.09 [CI 0.80–1.48]).
Karlinger and colleagues are not the first [9] to support the conclusion that greater use of professional interpretation decreases readmissions for LEP patients; however, a relationship with LOS was not found. This is not surprising as previous data is conflicting. A retrospective cohort study in a large academic center in the U.S. showed that interpreter use was associated with longer LOS [9]. The authors suggested this is likely because clinician use of interpreters is widely variable and they might be selectively using interpreters for their sicker patients who tend to have longer LOS. Two other retrospective studies, one in the U.S. [10] and one in Australia [11], found the opposite results, arguing improvement in communication accounted for the shorter hospital stays observed. There is, however, not a simple answer to this question, as LOS is in itself a complicated measure and shorter stays are not always better [12]. It is likely that professional interpreter use does increase and decrease LOS, as by improving communication a clinical presentation and course can either become (or be perceived as) more or less complex, leading to shorter or longer stays depending on the specific situation.
Can an interpreter improve patient outcomes? The short answer is “(probably) yes” and the long answer is “we are not (totally) sure.” The data are promising though, and since you may have some time to think about it the next time you’re patiently waiting for an interpreter, remember that you’re not only obeying the law and doing the right thing for your patient — you’re possibly preventing unnecessary readmissions as you speak.
Dr. Alvaro Vargas is a 2020 graduate of the NYU Langone Internal Medicine Residency
Peer reviewed by Christian Torres, MD, Editor in Chief of Clinical Correlations
Image courtesy of Wikimedia Commons
References
[1] US Department of Justice. Title VI of the Civil Rights Act. https://www.justice.gov/crt/fcs/TitleVI-Overview. Accessed September 2, 2017.
[2] US Department of Health and Human Services. Section 1557 of the Patient Protection and Affordable Care Act Washington, DC: HHS. 2016. https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/index.html. Accessed September 8, 2017.
[3] Basu, G., et al. Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency. AMA J Ethics. 2017; 19(3): 245-252. http://journalofethics.ama-assn.org/2017/03/ecas2-1703.html. Accessed September 21, 2017.
[4] US Census Bureau. Detailed languages spoken at home and ability to speak english for the population 5 years and over: 2009-2013. 2013. Available at:https://www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html. Accessed September 21, 2017.
[5] Divi C, Koss RG, Schmaltz SP, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19:60–67. https://academic.oup.com/intqhc/article-lookup/doi/10.1093/intqhc/mzl069. Accessed September 21, 2017.
[6] John-Baptiste A, Naglie G, Tomlinson G, et al. The effect of English language proficiency on length of stay and in-hospital mortality. J Gen Intern Med. 2004;19:221–228. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492154/pdf/jgi_21205.pdf Accessed September 21, 2017.
[7] Karliner LS, Kim SE, Meltzer DO, et al. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010;5:276–282. http://www.journalofhospitalmedicine.com/jhospmed/article/128310/language-barriers-and-hospital-care. Accessed September 21, 2017.
[8] Karliner, L. S., et al. Convenient Access to Professional Interpreters in the Hospital Decreases Readmission Rates and Estimated Hospital Expenditures for Patients With Limited English Proficiency. Medical Care. 2017. 55(3):199-206. https://insights.ovid.com/pubmed?pmid=27579909. Accesses September 21, 2017.
[9] Lopez L, Rodriguez F, Huerta D, et al. Use of interpreters by physicians for hospitalized limited english proficient patients and its impact on patient outcomes. J Gen Intern Med. 2015;30:1071–1080. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441652/. Accessed September 21, 2017.
[10] Lindholm M, Hargraves JL, Ferguson WJ, et al. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012; 27:1294–1299. https://link.springer.com/article/10.1007%2Fs11606-012-2041-5. Accessed September 21, 2017.
[11] Abbato, S., Greer, R., Ryan, J. et al. J Immigrant Minority Health (2018). https://doi-org.ezproxy.med.nyu.edu/10.1007/s10903-018-0830-6
[12] Southern, W. N., & Arnsten, J. H. Increased Risk of Mortality among Patients Cared for by Physicians with Short Length-of-Stay Tendencies. J Gen Intern Med. 2015; 30(6), 712–718. https://link.springer.com/article/10.1007%2Fs11606-014-3155-8