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      Increased Access to Professional Interpreters in the Hospital Improves Informed Consent for Patients with Limited English Proficiency

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          Abstract

          <div class="section"> <a class="named-anchor" id="d6359065e249"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e250">Background</h5> <p id="Par1">Language barriers disrupt communication and impede informed consent for patients with limited English proficiency (LEP) undergoing healthcare procedures. Effective interventions for this disparity remain unclear. </p> </div><div class="section"> <a class="named-anchor" id="d6359065e254"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e255">Objective</h5> <p id="Par2">Assess the impact of a bedside interpreter phone system intervention on informed consent for patients with LEP and compare outcomes to those of English speakers. </p> </div><div class="section"> <a class="named-anchor" id="d6359065e259"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e260">Design</h5> <p id="Par3">Prospective, pre-post intervention implementation study using propensity analysis.</p> </div><div class="section"> <a class="named-anchor" id="d6359065e264"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e265">Subjects</h5> <p id="Par4">Hospitalized patients undergoing invasive procedures on the cardiovascular, general surgery or orthopedic surgery floors. </p> </div><div class="section"> <a class="named-anchor" id="d6359065e269"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e270">Intervention</h5> <p id="Par5">Installation of dual-handset interpreter phones at every bedside enabling 24-h immediate access to professional interpreters. </p> </div><div class="section"> <a class="named-anchor" id="d6359065e274"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e275">Main Measures</h5> <p id="Par6">Primary predictor: pre- vs. post-implementation group; secondary predictor: post-implementation patients with LEP vs. English speakers. Primary outcomes: three central informed consent elements, patient-reported understanding of the (1) reasons for and (2) risks of the procedure and (3) having had all questions answered. We considered consent adequately informed when all three elements were met. </p> </div><div class="section"> <a class="named-anchor" id="d6359065e279"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e280">Key Results</h5> <p id="Par7">We enrolled 152 Chinese- and Spanish-speaking patients with LEP (84 pre- and 68 post-implementation) and 86 English speakers. Post-implementation (vs. pre-implementation) patients with LEP were more likely to meet criteria for adequately informed consent (54% vs. 29%, <i>p</i> = 0.001) and, after propensity score adjustment, had significantly higher odds of adequately informed consent (AOR 2.56; 95% CI, 1.15–5.72) as well as of each consent element individually. However, compared to post-implementation English speakers, post-implementation patients with LEP had significantly lower adjusted odds of adequately informed consent (AOR, 0.38; 95% CI, 0.16–0.91). </p> </div><div class="section"> <a class="named-anchor" id="d6359065e287"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e288">Conclusions</h5> <p id="Par8">A bedside interpreter phone system intervention to increase rapid access to professional interpreters was associated with improvements in patient-reported informed consent and should be considered by hospitals seeking to improve care for patients with LEP; however, these improvements did not eliminate the language-based disparity. Additional clinician educational interventions and more language-concordant care may be necessary for informed consent to equal that for English speakers. </p> </div><div class="section"> <a class="named-anchor" id="d6359065e292"> <!-- named anchor --> </a> <h5 class="section-title" id="d6359065e293">Electronic supplementary material</h5> <p id="d6359065e295">The online version of this article (doi:10.1007/s11606-017-3983-4) contains supplementary material, which is available to authorized users. </p> </div>

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          Most cited references36

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          How does communication heal? Pathways linking clinician-patient communication to health outcomes.

          Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patient's anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway. Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.
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            Language proficiency and adverse events in US hospitals: a pilot study.

            To examine differences in the characteristics of adverse events between English speaking patients and patients with limited English proficiency in US hospitals. Six Joint Commission accredited hospitals in the USA. Adverse event data on English speaking patients and patients with limited English proficiency were collected from six hospitals over 7 months in 2005 and classified using the National Quality Forum endorsed Patient Safety Event Taxonomy. About 49.1% of limited English proficient patient adverse events involved some physical harm whereas only 29.5% of adverse events for patients who speak English resulted in physical harm. Of those adverse events resulting in physical harm, 46.8% of the limited English proficient patient adverse events had a level of harm ranging from moderate temporary harm to death, compared with 24.4% of English speaking patient adverse events. The adverse events that occurred to limited English proficient patients were also more likely to be the result of communication errors (52.4%) than adverse events for English speaking patients (35.9%). Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient-provider encounter.
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              Effects of limited English proficiency and physician language on health care comprehension.

              To determine the effect of limited English proficiency on medical comprehension in the presence and absence of language-concordant physicians. A telephone survey of 1,200 Californians was conducted in 11 languages. The survey included 4 items on medical comprehension: problems understanding a medical situation, confusion about medication use, trouble understanding labels on medication, and bad reactions to medications. Respondents were also asked about English proficiency and whether their physicians spoke their native language. We analyzed the relationship between English proficiency and medical comprehension using multivariate logistic regression. We also performed a stratified analysis to explore the effect of physician language concordance on comprehension. Forty-nine percent of the 1,200 respondents were defined as limited English proficient (LEP). Limited English-proficient respondents were more likely than English-proficient respondents to report problems understanding a medical situation (adjusted odds ratio [AOR] 3.2/confidence interval [CI] 2.1, 4.8), trouble understanding labels (AOR 1.5/CI 1.0, 2.3), and bad reactions (AOR 2.3/CI 1.3, 4.4). Among respondents with language-concordant physicians, LEP respondents were more likely to have problems understanding a medical situation (AOR 2.2/CI 1.2, 3.9). Among those with language-discordant physicians, LEP respondents were more likely to report problems understanding a medical situation (AOR 9.4/CI 3.7, 23.8), trouble understanding labels (AOR 4.2/CI 1.7, 10.3), and bad medication reactions (AOR 4.1/CI 1.2, 14.7). Limited English proficiency is a barrier to medical comprehension and increases the risk of adverse medication reactions. Access to language-concordant physicians substantially mitigates but does not eliminate language barriers.
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                Author and article information

                Journal
                Journal of General Internal Medicine
                J GEN INTERN MED
                Springer Nature
                0884-8734
                1525-1497
                August 2017
                February 9 2017
                : 32
                : 8
                : 863-870
                Article
                10.1007/s11606-017-3983-4
                5515780
                28185201
                43b8c75d-8c26-4d0d-ba85-de8ffa1b3e0b
                © 2017

                http://www.springer.com/tdm

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