Limited English Proficiency and Clinical Outcomes After Hospital-Based Care in English-Speaking Countries: a Systematic Review

Woods, Amanda; Alonso, Andrea; Duraiswamy, Swetha; Ceraolo, Carl; Feeney, Timothy; Gunn, Christine M.; Burns, William R.; Segev, Dorry L.; Drake, Frederick Thurston

doi:10.1007/s11606-021-07348-6

Cited by 30 publications

(28 citation statements)

References 35 publications

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“…Although some studies mentioned no difference in hospital mortality, the Non-English speaking group's mortality was higher in our population (14.6% vs. 9.7%) [29,44]. LEP is often associated with ethnic minorities, such as Asians, Hispanics, African Americans, etc [24,44]. A number of recent studies have explored the potential discrimination and inherent prejudice against minorities in the process of disease diagnosis and use of aids, as well as the resulting unfair treatment [8,9,15,16].…”

Section: Discussioncontrasting

confidence: 70%

“…In the MIMIC cohort, present in eTable 12 , we noticed significantly longer ICU and hospital duration for Non-English speaking patients (LOS ICU day: 2.8 vs. 2.3 days; LOS hospital day: 8.0 vs. 7.3 days). Although some studies mentioned no difference in hospital mortality, the Non-English speaking group’s mortality was higher in our population (14.6% vs. 9.7%) [29,44]. LEP is often associated with ethnic minorities, such as Asians, Hispanics, African Americans, etc [24,44].…”

Section: Discussionmentioning

confidence: 69%

“…Due to communication barriers and inconsistencies in understanding, the dialogue time is prolonged, patients’ medical history cannot be effectively obtained, treatment plans cannot be effectively made, and communication with the patient’s family is affected. These could lead to misdiagnosis, delays in care, reduced quality of care, longer hospital stays, and reduced patient engagement and satisfaction [24,29,44]. In the MIMIC cohort, present in eTable 12 , we noticed significantly longer ICU and hospital duration for Non-English speaking patients (LOS ICU day: 2.8 vs. 2.3 days; LOS hospital day: 8.0 vs. 7.3 days).…”

Section: Discussionmentioning

confidence: 99%

“…Limited English proficiency is a common phenomenon in multilingual and multicultural countries in western countries, especially the U.S, and is continuing to have a deep impact on culture, economics, ethics, communication, and healthcare. Language barriers could adversely affect and profoundly challenge many aspects of healthcare covering medical access, quality, comprehension, and satisfaction [44]. Due to communication barriers and inconsistencies in understanding, the dialogue time is prolonged, patients’ medical history cannot be effectively obtained, treatment plans cannot be effectively made, and communication with the patient’s family is affected.…”

Section: Discussionmentioning

confidence: 99%

“…A recent study reported their LEP rate to be 11% in an academic medical center [25]. However, the impact of LEP on the quality of healthcare delivery has received little attention [25,26,44]. A newly published research analyzed the effect of LEP on mortality in 8974 patients with sepsis.…”

Section: Introductionmentioning

confidence: 99%

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Evaluating Prognostic Bias of Critical Illness Severity Scores Based on Age, Gender, and Primary Language in the USA: A Retrospective Multicenter Study

Liu

Shen

Lie

et al. 2022

Preprint

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Background Although severity scoring systems are used to support decision making and assess ICU performance, the likelihood of bias based on age, gender, and primary language has not been studied. We aimed to identify the potential bias of them such as Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation IVa (APACHE IVa) by evaluating hospital mortality across subgroups divided by age, gender, and primary language via two large intensive care unit (ICU) databases. Methods This multicenter, retrospective study was conducted using data from the Medical Information Mart for Intensive Care (MIMIC, 2001-2019) database and the electronic ICU Collaborative Research Database (eICU-CRD, 2014-2015). SOFA and APACHE IVa scores were obtained from the first 24 hours of ICU admission. Hospital mortality was the primary outcome. Patients were stratified by age (16-44, 45-64, 64-79, and 80-), gender (female and male), and primary language (English and non-English) then assessed for discrimination and calibration in all subgroups. To evaluate for discrimination, the area under receiver operating characteristic (AUROC) curve and area under precision-recall curve (AUPRC) were used. Standardized mortality ratio (SMR) and calibration belt plot were used to evaluate calibration. Findings A total of 173,930 patient encounters (78,550 MIMIC and 95,380 eICU-CRD) were studied. Measurements of discrimination performed best for the youngest age ranges and worsened with increasing age (AUROC ranging from 0.812 to 0.673 for SOFA and 0.882 to 0.754 for APACHE IVa, p <0.001). There was a significant difference in discrimination between male and female patients, with female patients performing worse. With MIMIC data, patients whose primary language was not English performed worse than English speaking patients (AUROC ranging 0.771 to 0.709 [p <0.001] for SOFA). Measurements of calibration applied to SOFA showed a statistically significant overestimation of mortality in the youngest patients (SMR 0.55-0.6) and underestimation of mortality in the oldest patients (SMR 1.54-1.57). When using SOFA, mortality is overestimated for male patients (SMR 0.92-0.97) and underestimated for female patients (SMR 1.05-1.11) while mortality is overestimated for English-speaking patients (SMR 0.85) and greatly underestimated for non-English speaking patients (SMR 1.4). In contrast, the calibration applied to APACHE-IVa shows underestimation of mortality for all age groups and genders. Interpretation The differences in discrimination and calibration with increasing age, female gender, and non-English speaking patients suggest that illness severity scores are prone to bias in their mortality predictions. Caution must be taken when using these illness severity scores for quality benchmarking across ICUs and decision-making for practices among a diverse population.

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Section: Discussioncontrasting

confidence: 70%

Section: Discussionmentioning

confidence: 69%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Evaluating Prognostic Bias of Critical Illness Severity Scores Based on Age, Gender, and Primary Language in the USA: A Retrospective Multicenter Study

Liu

Shen

Lie

et al. 2022

Preprint

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Association of Language Barriers With Perioperative and Surgical Outcomes

Joo,

Fernández,

Wick

et al. 2023

JAMA Netw Open

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ImportanceEnglish language proficiency has been reported to correlate with disparities in health outcomes. Therefore, it is important to identify and describe the association of language barriers with perioperative care and surgical outcomes to inform efforts aimed at reducing health care disparities.ObjectiveTo examine whether limited English proficiency compared with English proficiency in adult patients is associated with differences in perioperative care and surgical outcomes.Evidence ReviewA systematic review was conducted in MEDLINE, Embase, Web of Science, Sociological Abstracts, and CINAHL of all English-language publications from database inception to December 7, 2022. Searches included Medical Subject Headings terms related to language barriers, perioperative or surgical care, and perioperative outcomes. Studies that investigated adults in perioperative settings and involved quantitative data comparing cohorts with limited English proficiency and English proficiency were included. The quality of studies was evaluated using the Newcastle-Ottawa Scale. Because of heterogeneity in analysis and reported outcomes, data were not pooled for quantitative analysis. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline.FindingsOf 2230 unique records identified, 29 were eligible for inclusion (281 266 total patients; mean [SD] age, 57.2 [10.0] years; 121 772 [43.3%] male and 159 240 [56.6%] female). Included studies were observational cohort studies, except for a single cross-sectional study. Median cohort size was 1763 (IQR, 266-7402), with a median limited English proficiency cohort size of 179 (IQR, 51-671). Six studies explored access to surgery, 4 assessed delays in surgical care, 14 assessed surgical admission length of stay, 4 assessed discharge disposition, 10 assessed mortality, 5 assessed postoperative complications, 9 assessed unplanned readmissions, 2 assessed pain management, and 3 assessed functional outcomes. Surgical patients with limited English proficiency were more likely to experience reduced access in 4 of 6 studies, delays in obtaining care in 3 of 4 studies, longer surgical admission length of stay in 6 of 14 studies, and more likely discharge to a skilled facility than patients with English proficiency in 3 of 4 studies. Some additional differences in associations were found between patients with limited English proficiency who spoke Spanish vs other languages. Mortality, postoperative complications, and unplanned readmissions had fewer significant associations with English proficiency status.Conclusions and RelevanceIn this systematic review, most of the included studies found associations between English proficiency and multiple perioperative process-of-care outcomes, but fewer associations were seen between English proficiency and clinical outcomes. Because of limitations of the existing research, including study heterogeneity and residual confounding, mediators of the observed associations remain unclear. Standardized reporting and higher-quality studies are needed to understand the impact of language barriers on perioperative health disparities and identify opportunities to reduce related perioperative health care disparities.

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Language Matters: on the Inclusion of a Patient’s Preferred Language in the One-Liner

2023

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Limited English Proficiency and Clinical Outcomes After Hospital-Based Care in English-Speaking Countries: a Systematic Review

Cited by 30 publications

References 35 publications

Evaluating Prognostic Bias of Critical Illness Severity Scores Based on Age, Gender, and Primary Language in the USA: A Retrospective Multicenter Study

Evaluating Prognostic Bias of Critical Illness Severity Scores Based on Age, Gender, and Primary Language in the USA: A Retrospective Multicenter Study

Association of Language Barriers With Perioperative and Surgical Outcomes

Language Matters: on the Inclusion of a Patient’s Preferred Language in the One-Liner

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