Alice Hm Chen

Effects of Limited English Proficiency and Physician Language on Health Care Comprehension

AbstractOBJECTIVE: To determine the effect of limited English proficiency on medical comprehension in the presence and absence of language-concordant physicians. DESIGN, SETTING, AND PARTICIPANTS: 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. MEASUREMENTS AND MAIN RESULTS: 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). CONCLUSION: 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.

The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond

Over the past few decades, the number and diversity of limited English speakers in the USA has burgeoned. With this increased diversity has come increased pressure—including new legal requirements—on healthcare systems and clinicians to ensure equal treatment of limited English speakers. Healthcare providers are often unclear about their legal obligations to provide language services. In this article, we describe the federal mandates for language rights in health care, provide a broad overview of existing state laws and describe recent legal developments in addressing language barriers. We conclude with an analysis of key policy initiatives that would substantively improve health care for LEP patients.

Gender-Associated Differences in Emergency Department Pain Management

STUDY OBJECTIVE To determine whether patient or provider gender is associated with the number, type, and strength of medications received by emergency department patients with headache, neck pain, or back pain. DESIGN Prospective cohort study. SETTING Stanford University Hospital ED PARTICIPANTS: Patients 18 years and older who arrived at the ED with a chief complaint of headache, neck pain, or back pain between February 1, 1993, and September 30, 1993. Provider participants included medical students, interns, residents, nurse practitioners, and attending physicians. RESULTS ED administration of analgesic versus no analgesic, strength of analgesic administered, and administration of multiple medications. The study group consisted of 190 patients, 110 of them female. The patients were evaluated by 84 providers, 60 of them male. According to the providers surveyed, female patients described more pain than did male patients (P < .01) and were perceived by providers to experience more pain (P = .03). Female patients received more medications (P < .01) and were less likely to receive no medication (P = .01). Female patients also received more potent analgesics (P = .03). Linear and logistic regression analysis showed that patient perception of pain was the strongest predictor of the number and strength of medications given; patient gender was not a predictor. CONCLUSION Female patients with headache, neck pain, or back pain describe more pain and are perceived by providers to have more pain than male patients in the ED. Female patients also receive more medications and stronger analgesics. In this study, severity of patient pain rather than gender stereotyping appeared to correlate most with pain-management practices.

Not Perfect, but Better: Primary Care Providers’ Experiences with Electronic Referrals in a Safety Net Health System

BackgroundElectronic referrals can improve access to subspecialty care in safety net settings. In January 2007, San Francisco General Hospital (SFGH) launched an electronic referral portal that incorporated subspecialist triage, iterative communication with referring providers, and existing electronic health record data to improve access to subspecialty care.ObjectiveWe surveyed primary care providers (PCPs) to assess the impact of electronic referrals on workflow and clinical care.DesignWe administered an 18-item, web-based questionnaire to all 368 PCPs who had the option of referring to SFGH.MeasurementsWe asked participants to rate time spent submitting a referral, guidance of workup, wait times, and change in overall clinical care compared to prior referral methods using 5-point Likert scales. We used multivariate logistic regression to identify variables associated with perceived improvement in overall clinical care.ResultsTwo hundred ninety-eight PCPs (81.0%) from 24 clinics participated. Over half (55.4%) worked at hospital-based clinics, 27.9% at county-funded community clinics, and 17.1% at non-county-funded community clinics. Most (71.9%) reported that electronic referrals had improved overall clinical care. Providers from non-county-funded clinics (AOR 0.40, 95% CI 0.14-0.79) and those who spent ≥6 min submitting an electronic referral (AOR 0.33, 95%CI 0.18-0.61) were significantly less likely than other participants to report that electronic referrals had improved clinical care.ConclusionsPCPs felt electronic referrals improved health-care access and quality; those who reported a negative impact on workflow were less likely to agree. While electronic referrals hold promise as a tool to improve clinical care, their impact on workflow should be considered.

eReferral — A New Model for Integrated Care

In facing the challenge of taking better care of more patients at lower cost, health care organizations can learn from safety-net systems: one innovation prompted by clinical exigencies, eReferral, offers a new model for integrating primary and specialty care.

Evaluating Electronic Referrals for Specialty Care at a Public Hospital

BACKGROUNDPoor communication between referring clinicians and specialists may lead to inefficient use of specialist services. San Francisco General Hospital implemented an electronic referral system (eReferral) that facilitates iterative pre-visit communication between referring and specialty clinicians to improve the referral process.OBJECTIVEThe purpose of the study was to determine the impact of eReferral (compared with paper-based referrals) on specialty referrals.DESIGNThe study was based on a visit-based questionnaire appended to new patient charts at randomly selected specialist clinic sessions before and after the implementation of eReferral.PARTICIPANTSSpecialty clinicians.MAIN MEASURESThe questionnaire focused on the self-reported difficulty in identifying referral question, referral appropriateness, need for and avoidability of follow-up visits.KEY RESULTSWe collected 505 questionnaires from speciality clinicians. It was difficult to identify the reason for referral in 19.8% of medical and 38.0% of surgical visits using paper-based methods vs. 11.0% and 9.5% of those using eReferral (p-value 0.03 and <0.001). Of those using eReferral, 6.4% and 9.8% of medical and surgical referrals using paper methods vs. 2.6% and 2.1% were deemed not completely appropriate (p-value 0.21 and 0.03). Follow-up was requested for 82.4% and 76.2% of medical and surgical patients with paper-based referrals vs. 90.1% and 58.1% of eReferrals (p-value 0.06 and 0.01). Follow-up was considered avoidable for 32.4% and 44.7% of medical and surgical follow-ups with paper-based methods vs. 27.5% and 13.5% with eReferral (0.41 and <0.001).CONCLUSIONUse of technology to promote standardized referral processes and iterative communication between referring clinicians and specialists has the potential to improve communication between primary care providers and specialists and to increase the effectiveness of specialty referrals.

A Safety-Net System Gains Efficiencies Through ‘eReferrals’ To Specialists

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Airway reactivity in welders : A controlled prospective cohort study

In a 3-year survey, respiratory symptoms, spirometry, and methacholine reactivity were measured annually in welders (n = 51) and non-welder controls subjects (n = 54) to determine whether welding-related symptoms are associated with accelerated decline in lung function or changes in airway reactivity. In the cross-workshift study, maximal midexpiratory flow rate declined reversibly during a welding day, whereas 1-second forced expiratory volume and forced-vital capacity were unchanged. In the longitudinal study, the welders had significantly more reversible work-related symptoms of cough, phlegm, wheeze, and chest tightness than the non-welder shipyard control subjects. In this group of actively working welders, across-workshift changes in midflow and reversible symptoms were related to the welding occupation, but evidence for chronic irreversible effects on spirometry or airway reactivity was not seen over the 3 years of observation. The short period of observation was not optimal for detecting a chronic effect on lung function. Work practices and engineering controls may be successfully preventing irreversible respiratory effects, but not mild reversible effects, in this group of welders.

Literacy and Language: Disentangling Measures of Access, Utilization, and Quality

A 47-year-old man was found to have advanced lung cancer. After discussing options with his primary care physician, the patient decided in favor of palliative care. His physician referred him for home hospice. Two months later, the patient’s brother called because the patient had been having intractable pain. Because the patient had lost his insurance, home hospice had rejected the referral and sent him to a social worker, who gave the patient a Medicaid application. Neither the patient nor his brother had been able to read or complete the form. The brother eventually submitted the form with the assistance of the physician. Two weeks after the patient died, his brother received a letter informing him that the patient had qualified for Medicaid.A Spanish-speaking woman with claudication was found by her primary care physician to have a 5.5 cm abdominal aortic aneurysm (AAA) and was referred for consideration of surgery. A consultation was faxed to the Surgery Department and a copy given to the patient. At the follow-up visit, when the physician asked her whether she had decided to proceed with surgery, the patient informed her physician that no surgery was necessary. The surgeon’s note in the chart described the claudication symptoms and recommended the patient increase her walking; there was no mention of the AAA. The patient acknowledged that she had not handed the consultation form to the surgeon because she couldn’t read it and did not know what it was for. The patient was re-evaluated, but the AAA had expanded to the renal arteries. The patient ultimately went to surgery but did not survive the operation.An elderly Cantonese-speaking woman was hospitalized because she had taken too much warfarin. Late that night, she got up to go to the bathroom. A nurse on duty stopped her and tried to get her back into bed. When the patient persisted in wanting to go to the bathroom, the nurse thought she was agitated. Instead of getting an interpreter, the nurse had the patient put in restraints, and gave her a sedative. When she didn’t respond immediately to the sedative, the staff gave her more. By morning, she was barely responsive.

Improving the Primary Care―Specialty Care Interface: Getting From Here to There

M S JONES PRESENTS TO HER PRIMARY CARE physician (PCP), Dr Sanchez, with symptoms of persistent diarrhea. Using prereferral guidelines posted on his practice’s electronic referral system, he rules out Clostridium difficile, other bacterial and parasitic infections, and celiac disease. He refers her to a gastroenterologist, Dr Lee, for further evaluation and possible colonoscopy. When Ms Jones arrives, Dr Lee reviews the electronic referral, which includes Dr Sanchez’s contact information and consultative question along with the patient’s relevant history and laboratory results. After assessing Ms Jones, Dr Lee discusses the risks and benefits of colonoscopy with her to further evaluate the diarrhea. After the visit, Dr Lee dictates a note outlining the findings of the patient’s assessment and the recommendations to Dr Sanchez. Within 2 days, the note can be found in the electronic medical record that both physicians use.