1、Language Barriers and Medical Interpretation,Academy Health “National Standards For Culturally “interpreters” and translators and data collection methods Role of IRBs Research agenda Budgets and funding; involvement of Interpreter Services,E Hardt 2005,The Exclusion of Non-English-Speaking Persons f

2、rom Research,Survey of 172 responding researchers on provider-pt relations Only 22% included LEPs who were potential subjects Reasons for exclusions: didnt think of it translation issues staffing issues no potential LEP subjects,Frayne SM et al J Gen Intern Med 1996,PROVIDER MAY NOT OCR:,Provide ser

3、vice to LEP clients that are more limited in the scope or that are lower in quality than those provided to other persons Subject a LEP client to unreasonable delays in the provision of services Limit participation in program or activity on the basis of English proficiency Provide services to LEP per

4、sons that are not as effective as those provided to those who are proficient in English Require a LEP client to provide and interpreter or to pay for the services of an interpreter,VNS of Western MA: OCR Action I,July 1998 intake RN and supervisor refused to accept referral of Spanish-speaking diabe

5、tic because “she didnt speak English and had no one to interpreter for her at home” They claimed that this was “the new policy caused by budget cuts” Patient was a recipient of Medicare/Medicaid Case reported to OCR by RN on behalf of pt.,VNS of Western MA: OCR Action II,By November 1998 the VNS had

6、 entered into a compliance agreement with the OCR: Services for LEP patients were restored VNS contracted with a telephone interpretation agency and instructed staff re its utilization Bilingual staff were recruited and hired and matched to patients when possible The VNS was deemed by the OCR to be

7、once again in compliance with Title VI of the Civil Rights Act of 1964 and eligible for federal money,Studies on Language Barriers,Satisfaction Access Utilization of Health Care Quality of Care Costs Interventions,Impact of Language Barriers on Patient Satisfaction in an Emergency Department,Survey

8、of 2333 pts in 5 urban academic EDs 15% NES (? LEP status) Overall satisfaction: 52% for NES vs. 71% for ES Willingness to return: 86% for NES vs. 91.5% for ES NES pts more likely to report overall problems with care, communication and testing,Carrasquillo O et al JGIM 1999,Effect of Spanish Interpr

9、etation Method on Patient Satisfaction,233 Eng-speaking ES and 303 Span-speaking SS pts in CO urban walk-in clinic, mean age 32 128 of SS seen by language concordant MD LC 59 SS used AT telephone/mail survey in Eng but only 45 % satisfied with ability to educate and empower the PTs about Dx, Rx, med

10、s Previous training in interpreter collaboration was associated with higher IS use and better satisfaction with medical care,Karliner L et al, JGIM 2004,Studies on Language Barriers,Satisfaction Access Utilization of Health Care Quality of Care Costs Interventions,One in Five Have Gone Without Care

11、When Needed Due to Language Obstacles,HQ11: In the course of the past year, how many times were you sick, but decided not to visit a doctor because the doctor didnt speak Spanish or have an interpreter? Source: Wirthlin Worldwide 2002 RWJF Survey,19% Have Not sought care when needed due to language

12、barrier,Racial/Ethnic Differences in Childrens Access to Care,Data from 1996 Medical Expenditure Panel Survey (MEPS) 6900 US children, 9% lacking usual source of care 6.0% of Whites, 12.5% of AAs, 17.2% of Hispanics For Hispanics, 40.7% were interviewed in Spanish, 59.3% were interviewed in English

13、Hispanic LEPs 27% as likely as Whites to have regular source of primary care No difference between English-speaking Hispanics and Whites,Weinick RM et al Am J Public Health 2000,Smoking Cessation Counseling,Source: The Commonwealth Fund 2001 Health Care Quality Survey.,Percent of current smokers cou

14、nseled by physician to quit,Slide 7,Studies on Language Barriers,Satisfaction Access Utilization of Health Care Quality of Care Costs Interventions,Does a Physician-Patient Language Difference Increase the Probability of Hospital Admission?,Prospective observational study of 653 adult AP and 79 pedi

15、atric PP pts in the ED at NYU Med Center Queens 14.7% of APs and 12.7% of PPs preferred non-English NES 52% of NES APs and 17% of NES PPs used “interpreters” No trained or professional interpreters were used NES APs were more likely to be admitted than ES controls, 35% vs. 21%, RR 1.70 1.14-2.53. No

16、 difference for PPs. Difference persisted after multivariate analysis for age, gender, acuity level, and presence of an “interpreter”.,Lee ED et al Acad Emerg Med 1998.,Effect of English Language Proficiency on Length of Stay I,Retrospective review of administrative data on consecutive admissions to

17、 3 major Toronto teaching hospitals 1993-1999 LOS differences analyzed for 23 medical and surgical conditions 59,547 records and then meta-analysis of 220 case mix groups 189,119 records Similar analysis for in-hospital mortality,John-Baptiste A et al, JGIM 2004,Effect of English Language Proficienc

18、y on Length of Stay II,LOS for LEP patients longer for 7 of 23 conditions unstable coronary syndromes and chest pain, CABG, stroke, craniotomy, diabetes, hip replacement, GI procedures Differences range from 0.7 to 4.3 days Overall LEP LOS 6% longer approx 0.5 days No increased risk of in-hospital d

19、eath,John-Baptiste A et al, JGIM 2004,Studies on Language Barriers,Satisfaction Access Utilization of Health Care Quality of Care Costs Interventions,Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia,139 pts with long bone fracture in UCLA ED 108 NHWs, 31 Hispanic (42% NES, ?L

20、EP) Hispanics twice as likely to get no ED pain Rx OR 7.46; 95% CI, 2.22-25.02; p0.01 NES status was borderline significant predictor OR 3.12; 95% CI, 0.98-9.83; p=0.052,Todd KH et al JAMA 1993,Understanding Instructions for Prescription Drugs Those Prescribed Medication,Source: Andrulis D, et al. W

21、hat a Difference an Interpreter Can Make: Health Care Experiences of Uninsured with Limited English Proficiency, March 2002,Quality of Diabetes Care for Non-English-Speaking patients: A Comparative Study,Retrospective cohort study of 622 diabetics, 93 LEPs Academic medical center and county hospital

22、 Virtually all LEPs (24 languages) arrived with professional interpreters LEPs more likely to get 2 or more Hgb AlC per year 2 or more clinic visits per year 1 or more dietary consults No differences in other labs, complications, use of other services, and total changes.,Tocher TM et al West J Med 1

23、998,Studies on Language Barriers,Satisfaction Access Utilization of Health Care Quality of Care Costs Interventions,Language Barriers and Resource Utilization in a Pediatric ED,2467 patients in an urban, academic pediatric ED 12% LEP, 8.5% with LB with MD For cases with LB: higher test ($145 vs. $10

24、4) Longer ED stay (165 vs. 137 minutes) Analysis of covariance: LB accounted for $38 and 20 minutes,Hampers Pediatrics 1999 LC et al,Does the Use of Trained Medical Interpreters Affect ED Services, Charges, and Follow-up?,Retrospective chart reviews of 503 pts in Boston Med Ctr ED CC: CP/SOB, HA, AB

25、D pain, pelvic pain/vag bleeding 66 Eng-speakers ESPs, 63 Spanish, Haitian, Cape Verdean pts using hospital interpreters IPs, 374 LEP pts not using interpreters NIPs NIPs had shortest ED stay p .001 and fewest tests p .04 and prescriptions p .03 IPs were more likely to make clinic follow-up and less

26、 likely to return to the ED than NIPs p .03 Among non-admitted pts, return visit ED charges and total subsequent 30 day charges were reduced for IPs compared to NIPs and ESPs.,Bernstein J et al. Journal of Immigrant Health 2002; 4: 171-176.,Language Barriers in Health Care: Costs and Benefits of IS,

27、Follow up analysis of intervention study at major HMO as it increased interpreter services IS Average cost of IS per LEP member $234/yr For HMO overall, total costs averaged $0.20 per member per month Average cost of IS encounter $79 at the time which can be expected to decline with increasing effic

28、iency,Jacobs E, et al. AJPH 2004; 94:366-369,Studies on Language Barriers,Satisfaction Access Utilization of Health Care Quality of Care Costs Interventions,Effects of Interpreters on the Evaluation of Psychopathology in Non-English-Speaking Patients,2 Public hospitals in NYC with no official interp

29、reters 30 psychiatric interpreter-interviews daily Interpreters were other pts, friends, family, staff Open discussions with providers and bilingual employees Content analysis of 8 audio-taped interviews Distortions resulted from interpreters poor language skills, lack of psychiatric knowledge, and

30、attitudinal issues,Marcos LR Am J Psychiatry 1979,When Nurses Double as Interpreters: Spanish-speakers SS in Primary Care,21 SS pts with first walk-in visit to primary care clinic with untrained nurses used to interpret Transcripts revealed serious miscommunication that affected understanding or cre

31、dibility in 1/2 cases MDs resisted reconceptualization in face of contradiction Nurse provided data expected clinically vs. actual Nurse interpretation reflected unfavorably on pts Pts used cultural metaphors incompatible with Western clinical nosology not always interpreted,Elderkin-Thompson et al,

32、 Soc Sci Med 2001,Impact of Interpretation Method on Clinic visit Length,Time motion study of 613 visits to PCU in RI with 28% LEP pts 90% Span-speakers Interpreted pts spent longer in clinic 93.6 vs. 82.4 and w/ provider 32.4 vs. 28.o Patients using telephone and patient-provided interpreters took

33、longer; those using hospital interpreters did not Authors calculated potential cost savings of reduced telephone usage and more efficient MD utilization in terms of potential hospital interpreters hired,Fagan MJ et al JGIM 2003; 18: 634-638,Medical Interpreters Have Feelings Too I,Anonymous question

34、naire of all 22 members of interpreter service of GRC 5 had exposure to severe trauma war, torture, detention, beatings 7 reported more than 50 % of sessions involved patients with exposure to violence 5 frequently experienced difficult feelings during interpreting sessions,Medical Interpreters Have

35、 Feelings Too II,66 % had frequently painful memories 83 % reported seeing patients outside of the consultation setting Interpreters expressed the need to talk and share feelings after the session with the medical doctor 83 % or with relatives or spouse 44 %,Louton L et al Soz Praventivmed 1999,Mand

36、ates for Medical Interpreter Services,CLAS Standards Office of Civil Rights ORC position State laws 26 states and increasing Regulatory and review organizations (JCAHO, NCQA Risk management Possible cost savings, market opportunities Outcomes, quality Justice,Massachusetts ED Interpreter Bill Effect

37、ive July 1, 2001,Section 25J. Every acute-care hospital shall provide competent professional interpreter services in connection with all emergency room services and acute inpatient psychiatric services provided to a non-English- speaker or person who has difficulty in speaking or understanding the English language. Section 3c. Any non-English- speaker who is denied effective health care services by a health care provider by reason of the providers not providing competent professional interpr