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JGIM: studies show importance of language services on disparities, quality of care

Princeton, N.J. New studies published today in a special supplement to the Journal of General Internal Medicine (JGIM) examine the consequences of language barriers for patients who speak little, if any, English and the impact of the absence of language services in health care settings. The studies overall report that measurable disparities in quality of care result when patients and providers do not speak the same language.

  • Hospitalized Patients Who Speak Little English May Be Less Likely to Give Consent Before Undergoing Invasive Procedures

  • Hispanics Who Speak Little English Are Less Likely to Receive All Recommended Health Care Services

  • One in Five Staff Interpreters Do Not Have Competent Bilingual Skills

  • 17th U.S. Surgeon General Carmona Joins Dialogue

The supplement is sponsored by Hablamos Juntos, an initiative of the Robert Wood Johnson Foundation, as part of its efforts to improve the quality of care for all Americans by addressing racial and ethnic disparities in health care. Nearly one in five people in the United States now speak a language other than English at home. And while many can comfortably speak English when needed, experts estimate some 20 million people in America about one in every 15 people in the U.S. speak and understand little, if any English. This means that health care providers are increasingly facing the challenge of how to communicate efficiently and effectively with patients who have limited English proficiency (LEP). Hablamos Juntos, administered by UCSF Fresno Center for Medical Education and Research, seeks to develop practical and affordable solutions to increase the availability and quality of language services, interpretation, translation and signage.

> Study: Hospitalized Patients Who Speak Little English Are Less Likely to Have Documentation of Informed Consent Prior to Invasive Procedures

This study showed that, despite the availability of on-site professional interpreter services, hospitalized patients who do not speak English are less likely to have signed consent forms in their medical records. Researchers from the Department of Medicine at the University of California, San Francisco, compared records of LEP and English-speaking patients for full documentation of informed consent a legal and ethical requirement prior to invasive, non-emergency medical procedures. Full documentation includes a note documenting a consent discussion and a signed consent form. For LEP patients, it also requires some evidence of interpretation.

Although the health care system has a long way to go in improving performance on informed consent for all patients, the results of this study showed that charts of English-speaking patients were nearly twice as likely as those of LEP patients to contain all elements of informed consent (53% vs. 28%). When examining the components of informed consent, charts of English-speaking and LEP patients were similar in the proportion documenting that a consent discussion took place, but charts of English-speaking patients were more likely to contain a signed consent form in any language (85% vs. 70%). The researchers conclude these findings suggest differences in practice, not documentation alone.

Informed consent is a fundamental tenet of the U.S. health care system, said lead researcher Yael Schenker, M.D. While language barriers make obtaining informed consent more complex, it is still a legal and ethical requirement and is increasingly recognized as a key component of quality care and patient safety. Hospitals must work harder to break down the language barriers faced by LEP patients.

Senior author Alicia Fernandez M.D., reported that the hospital leadership has responded very appropriately to the study findings, and the hospital has substantially revised its informed consent process to ensure that all patients have properly consented prior to invasive procedures.

> Study: Hispanics Who Speak Little English Are Less Likely to Receive All Recommended Health Care Services

A second study looked to see if the primary language spoken in a household identified whether Hispanic patients were at greater risk for not receiving the recommended health care services. Lead researcher Eric M. Cheng, M.D., of the VA Greater Los Angeles Healthcare System, compared the receipt of 10 recommended health care services between white, English-speaking patients and Hispanics who were uncomfortable speaking English in a nationally representative survey. Hispanics who did not speak English at home were significantly less likely to receive all the eligible health care services (57% vs. 35%).

Clearly, language usage predicts the quality of clinical care that patients receive, said Cheng. While the reasons for this are being investigated, the consequences are unequivocally unacceptable. Expanding access to medical interpreters, as is currently required of hospitals that receive federal funding, in the outpatient setting will likely be an important component of interventions designed to improve the quality of health care in this population.

> Study: One in Five Staff Interpreters at a Large Health Care Organization Do Not Have Competent Bilingual Skills

A third study in the supplement assessed the bilingual skills of dual-role staff interpreters individuals whose primary responsibility is in another area, but who often provide ad hoc medical interpretation between health care providers and LEP patients. Lead researcher Maria R. Moreno, of Sutter Health in Northern California, tested bilingual staff who interpret for accuracy, comprehension, communication and medical terminology in both English and the second language. The majority of those tested worked as administrative assistants, medical assistants and clinical staff. Results showed that two percent failed the competency test, and 21 percent had only a limited ability to read, write and speak both languages. The study uncovered interpretation errors, including omissions and word confusion, which would be likely to negatively affect clinical outcomes and potentially lead to medical errors.

Having untested and untrained bilingual staff serving as medical interpreters presents a potential risk. Professional interpreter services increase physician-patient communication, safety and satisfaction, said Moreno. With the absence of guidelines and a formal certification process to demonstrate interpreter competence, many health care facilities across the country may not be providing the best possible care to all patients.

> 17th Surgeon General Speaks Out

In a foreword to the supplement, Richard H. Carmona, M.D., Surgeon General of the United States 2002-2006, discussed his familys experiences and the vital importance of culturally and linguistically appropriate health information.

Until my family found a local doctor who spoke Spanish and understood our culture, we often struggled to understand what we needed to do to prevent diseases or to recover from illness or injuries, said Carmona. Language difficulties can create a wall of confusion and misunderstanding between health professionals and the people we are trying to serve, essentially becoming barriers to quality care. Our nation must increase its determination to serve diverse populations by providing culturally and linguistically appropriate care to our patients.

> Foundation Affirms Its Commitment to Issue

In sponsoring the supplement, the Robert Wood Johnson Foundation reiterated its commitment to programs that bring more equality to the health care system. The Foundation leads national initiatives to improve the availability and quality of language services in hospitals and other health care settings.

The quality of health care for all Americans will not be improved without a concentrated effort to ensure that people with limited English-speaking proficiency have access to language services and assistance in clinical encounters within Americas hospitals and health systems, said Risa Lavizzo-Mourey, M.D., MBA, president and CEO of the Robert Wood Johnson Foundation. I am hopeful that, with continued vigilance, we will identify solutions to address language barriers that affect the quality of patient care.


Contact: Nick Ferreyros

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