Limited English Patients Are More Likely To Return To The E.R

Patients with limited English in the emergency room are slightly more likely to return within days, suggesting their care the first time was not as good as it could have been, researchers say.

In a study in one New York hospital, about 4 percent of English speakers made an unplanned return to the ER within three days, compared to 5 percent of people with limited English.

Low use of professional translators may partly explain the disparity in care, the researchers report in the Annals of Emergency Medicine.

“There’s a necessary but not sufficient step to providing care for people with low English proficiency . . . having a good interpreter or healthcare provider who can speak to them in their language,” said Dr. Elizabeth Jacobs of the University of Wisconsin-Madison, who was not part of the new study.

The study team, led by Dr. Ka Ming Ngai of the Icahn School of Medicine at Mount Sinai in New York, analyzed 2012 data from the Mount Sinai emergency department. More than 32,000 adult patients and 45,000 ER visits were included. The study did not include patients with psychiatric or substance-related complaints, those who were nonverbal or had altered mental status, and those with a history of frequent ER visits.

Almost 3,000 patients had limited English proficiency, and in about half of cases someone served as an interpreter. Usually, this was a family member or an ER staff member. Only 527 visits in this group, 24 percent, involved a professional interpreter.

More than a quarter of patients were admitted to the hospital and 1,380 patients had an unplanned return to the ER within three days.

After accounting for age, sex, insurance, race, ethnicity, triage category and other health problems, having limited English proficiency was not tied to greater risk of being admitted to the hospital.

But those with limited English proficiency were about 24 percent more likely to return to the ER unexpectedly.

Ngai told Reuters Health by email that he has been studying the problem of language barriers for the past six years and over time has seen some improvements.

"New medical students are now routinely educated to use interpreter phones during their clinical simulation . . . however, there are still many barriers including access to interpreters and interpreter phones, time constraints, and (doctors) trying to 'get by' with their own language skills," he said.

Ngai said regulatory bodies require hospitals to make language services available. In New York State, for example, upon a request to the hospital administration by the patient, the patient’s family or representative, or the provider of medical care, hospitals must provide translation services in inpatient and outpatient settings within 20 minutes and in emergency settings with 10 minutes.

Most New York Hospitals use an interpreter phone service, he said.

Patients who struggle to speak the local language are “a really important population to study and think about how we can improve their care,” Jacobs said.

A 5 percent rather than 4 percent rate of return to the ER is not a large difference, but that could be due to the large number of patients excluded from the study, and because there was no validated measure of English proficiency, Jacobs said.

“That might be why we didn’t see large differences, if some people considered low English proficiency actually spoke English well, or were getting good interpretive services,” she said. “If you took them out, the difference might be larger.”

Patients who do not speak English may struggle in other areas of the health system more than at the ER, she added.

But even having an interpreter at the hospital won’t help patients deal with insurance providers, she noted.

“There are contextual issues that you may not be able to fully adequately address unless you can understand the nuances,” Jacobs said.

"When dealing with immigrant population, it is almost always more than 'just' language," Ngai agreed. There can be cultural issues, too.

In addition, people with low English proficiency may also be less able to take days off of work, and to agree to be admitted to the hospital when necessary, than others, Jacobs said.

“We’ve made tremendous progress in assuring interpreters are more available,” in person, over the phone or by video, Jacobs said.

But, she said, “we are very imperfect at getting patients the services they need. It’s important for providers to be educated on these issues and to understand how to access these services.”

It would be ideal to try to match patients with providers by language and culture, but in the meantime, "language is a good start," Ngai said.

 

From Reuters.com

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