Language Barriers and Medical Interpretation Academy Health June 27 2005 Boston MA “National Standards For Culturally Linguistically Appropriate Behavioral Health Ca

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Language Barriers and Medical Interpretation Academy Health June 27 2005 Boston MA “National Standards For Culturally Linguistically Appropriate Behavioral Health Ca Powered By Docstoc
					   Language Barriers and
   Medical Interpretation
Academy Health                  June 27, 2005, Boston, MA

 “National Standards For Culturally & Linguistically
Appropriate Behavioral Health Care: Are We Kidding

   Eric J. Hardt MD
   Clinical Director, Geriatrics Section, Boston Medical Center
   Medical Consultant to Interpreter Services
Linguistic Minorities in the USA
        Definition of NES, LEP

                 NES             LEP
USA    1990    13.8 %            6.0 %
USA    2000    17.9 %            8.1 %
 MA    2000    18.7 %            8.1 %
Boston 2000    33.4 %            16.3 %
NYC    2000    47.6 %            23.7 %
LA     2000    57.8 %            32.6 %
Language and Access Mandates

4. Offer and provide language timely
   assistance services without charge
5. Inform patients of their right to
   receive language assistance services
6. Interpreters and bilingual staff
7. Patient-related materials and signage
Interactions between Culture and
• Scenarios that include language
  barriers are very likely to present
  “cross-cultural” issues:

  – Bias/discrimination/stereotypes/racism
    [both personally-mediated and institutionalized]
  – Culturally-mediated diversity in health-related
  – Power differentials
                                         E Hardt 2005
  Roles for Medical Interpreters
 in Relation to “Cultural” Issues
• Interpreter is the conduit via which the
  culturally competent provider may explore
  differences in health related beliefs and
• Interpreter adopts an expanded role that
  includes explanation of features of medical and
  of patient culture and brokerage of
  relationships between patient and provider
                                        E Hardt 2005
         Clinical Issues I
• Outreach and marketing, signage,
  telephone access
• “Taking a history” and doing the PE
• Clinical evaluation [ e.g. CAGE, Folstein
  MMSE, peak flow]
• Ordering, interpretation, and performance
  of tests [e.g. CAT, MRI, ETT, PFTs]
• Procedures [ e.g. colonoscopy, conscious
  sedation, labor and delivery ]
• Patient education, counseling, discharge
  instructions, preps, written materials
                                    E Hardt 1988
         Clinical Issues II
• Consent for treatment/procedures/studies
• Follow-up of test results, appointment
• Medication compliance, adverse drug
  reactions, allergies
• Cost containment, managed care
• Risk management, medical errors,
  standards of care
• Doctor-patient relationships, patient
                                 E Hardt 1988
   Research Data and

Needed to change attitudes of
    law and policy makers,
  remodel provider behavior
and clinical systems, establish
  credibility for interpreters.
Do We Have Health Care
 Disparities related to
  Language Barriers?

   How big are they? For what
groups? In what areas? How do
 we document them? What are
 the costs? What can be done?
    Who should be doing it?
  Selected Research Issues
• Inclusion of potential LEP subjects
• Translation and validation of instruments
• Research infrastructure and personnel,
  information systems
• Definitions [ PLINE, NES, LEP; “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 from Research
• Survey of 172 responding researchers on
  provider-pt relations
• Only 22% included LEPs who were potential
• Reasons for exclusions:
  –   didn’t think of it
  –   translation issues
  –   staffing issues
  –   no potential LEP subjects

                             Frayne SM et al J Gen Intern Med 1996
• Provide service 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 persons 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
  diabetic because “she didn’t 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 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 once
     again in compliance with Title VI of the Civil
     Rights Act of 1964 and eligible for federal money
    Studies on Language
• Satisfaction
• Access
•   Utilization of Health Care
•   Quality of Care
•   Costs
•   Interventions
Impact of Language Barriers on
   Patient Satisfaction in an
   Emergency Department
• Survey 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

                   Carrasquillo O et al JGIM 1999
  Effect of Spanish Interpretation
  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&T, 69 SS used family members,
  47 SS used ad hoc interpreters
• Overall satisfaction was identical for ES, LC, and
  AT&T at 77 % Vs 54 % for those using family
  and 49% for those using ad hoc interpreters

                        Linda Lee et al, JGIM 2002
      Patient Assessment of
      Medicaid Managed Care
• Consumer Assessment of Health Plans
  Study [49,327 PTs/14 states, 1999-2000]
• Linear regression model within/between
  plans; telephone/mail survey in Eng & Span
• NES reported lower ratings of care [access,
  timeliness, provider communication, staff
  helpfulness, & composite]
• White NES and Hispanic Spanish-speakers
  clustered in worse plans
• Most observed racial/ethnic difference in
  ratings attributable to within plan variation
  including those for NES Asians

                   Weech-Maldonado et al, JGIM 2004
  Importance of MD Training in
 Use of Interpreters in the OPD

• 158 MD questionnaires about last clinic visit
  involving an interpreter [?type] at SFGH
• 85 % satisfied with ability to Dx and Rx; but
  only 45 % satisfied with ability to educate
  and empower the PTs about Dx, Rx, meds
• 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
• Satisfaction
• Access
•   Utilization of Health Care
•   Quality of Care
•   Costs
•   Interventions
 One in Five Have Gone Without Care When
   Needed Due to Language Obstacles

      19% Have Not sought care when needed due to language barrier

HQ11: In the course of the past year, how many times were you sick, but decided not
   to visit a doctor because the doctor didn’t speak Spanish or have an interpreter?

                                       Source: Wirthlin Worldwide 2002 RWJF Survey
    Racial/Ethnic Differences in
     Children’s Access to Care
• Data from 1996 Medical Expenditure Panel Survey
• 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
• 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
                                                                              Slide 7

                Smoking Cessation Counseling
       Percent of current smokers counseled by physician to quit


        79%       82%
                                                  68%        67%


        Total     White     African   Hispanic    Asian     Hispanic   Hispanic
                           American              American   English-   Spanish-
                                                            Speaking   Speaking

   Source: The Commonwealth Fund 2001 Health Care Quality Survey.
  Studies on Language
• 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 pediatric
  [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 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 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
   Proficiency 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 death

                  John-Baptiste A et al, JGIM 2004
  Studies on Language
• 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, ?LEP)
• Hispanics twice as likely to get no ED pain
  Rx [OR 7.46; 95% CI, 2.22-25.02; p<0.01]
• NES status was borderline significant
  predictor [OR 3.12; 95% CI, 0.98-9.83;

                         Todd KH et al JAMA 1993
   Understanding Instructions for
Prescription Drugs Those Prescribed
             95%                      97%

  75%                                                         67%

                    2%                      2%     5%                       7%
          No Interpreter Needed         Interpreter         Interpreter Needed
                                     Needed/Available          Not Available

 Understood Instructions            Did Not Understand             No instructions Given

Source: Andrulis D, et al. What 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
• Academic medical center and county hospital
• 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 1998
    Studies on Language
•   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. $104)
  – 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, ABD 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 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
• 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 efficiency
                Jacobs E, et al. AJPH 2004; 94:366-369
    Studies on Language
•   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
• 30 psychiatric interpreter-interviews daily
• Interpreters were other pts, friends, family, staff
• Open discussions with providers and bilingual
• Content analysis of 8 audio-taped interviews
• Distortions resulted from interpreters’ poor
  language skills, lack of psychiatric knowledge,
  and 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 credibility in 1/2 cases
• MDs resisted reconceptualization in face of
• 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, 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 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 questionnaire 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
• 5 frequently experienced difficult feelings
  during interpreting sessions
  Medical Interpreters Have
       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
     Mandates for Medical
     Interpreter Services
•   CLAS Standards
•   Office of Civil Rights [ORC] position
•   State laws [26 states and increasing]
•   Regulatory and review organizations
•   Risk management
•   Possible cost savings, market
•   Outcomes, quality
•   Justice
Massachusetts ED Interpreter Bill
                 [Effective 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 provider’s not
  providing competent professional interpreter
  services should have a right of action in a
  superior court.
• Governmental units are to reimburse the cost of
  interpreters for any mandated provider.
           Selected Issues re
• Documentation: language status of patient
    in IS; interpreter utilization by site, shift,
    language, etc.
•   Risk Management: informed consent, staff
    education re expectations and availability
•   Clinical outcome measures including
    satisfaction, utilization, and quality
•   Research inclusion and activity, related
•   Training activity for staff and interpreters;
    notification of rights for patients
                                            E Hardt 2005
   Might Language Competence
  Facilitate Cultural Competence?
• Skills training viz language may invite and
  synergize with efforts to learn content and
  change attitudes while starting with a less
  threatening set of goals
• Interpreter Services Department often
  catalyze/lead organizational efforts at CC
• Methodology of organization’s approach to
  language-based disparities can model
  approach to other areas of disparities and
  growth potential
                                     E Hardt 2005
References and Bibliography

• See NCIHC website [ National Council
  on Interpreting in Health Care],
• for annotated
  bibliography August 2003
• email me at:

Description: Language Barriers in Education document sample