The Effect of Professional Medical Interpretation in the Pediatric ED

Louis Hampers, MD, MBAMedical Director, Emergency Department

Associate Professor of PediatricsUniversity of Colorado School of Medicine

The Problem

• 2000 Census

– For 18% of US residents, English is not primary language

– 8% limited English proficient (LEP)

The Problem

• Patient/Provider language barriers negatively impact:– access– efficiency– satisfaction– quality

• errors• adherence• baseline health

The “Truth”

• Daily occurrence of unaddressed language barriers in the US is an open secret

• Survey of pediatric residents at TCH– 19 “proficient” in Spanish– 40 “nonproficient” in Spanish

• 21 used their “Spanish” ‘often’ or ‘everyday’• 32 admitted “avoiding communication” with LEP families

Pediatrics 2003;5:e569

Excuses?

• Ad hoc interpreters “good enough”• Professional interpreters slow things down• Patients didn’t ask for/don’t want interpreters• ?HIPAA• Provider with “good enough” language skills• Insurance won’t pay• “This is America, we speak English”

Quality

• Audiotapes of 13 LEP encounters– 6 professional interpreters– 7 ad hoc

• mean 19 important errors/encounter– omission, false fluency, substitution,

edtiorialization, addition• Ad hoc significantly more likely to make

important errors

Pediatrics 2003;111:6

Interpreter Effect

• North side of Chicago

• University pediatric ED

• ~40,000 visits/yr

• ~50% Latino

• ~10% LEP

Archives of Pediatrics and Adolescent Medicine 2002;156:1108

Setting

• Winter 1997-1998– “on-call” interpreters– 42% coverage

• Winter 1999-2000– full-time interpreters (2.5 FTE’s)– 91% coverage

Professional Interpreters

• No certification in State of IL

• 40 hrs training

• 4 hrs “shadowing”

• Wage/benefits ~ $17/hr

• “Family Support Services”

• Payors not billed

DesignProspective

Inclusion:

T > 38.5oC

2 mo to 10 yrs + or

vomiting or diarrhea

Clinical appearance recorded

DesignProspective Cohorts

• Does this patient’s family speak English?

• Did this present a language barrier for you?

• Did you use an interpreter?

Cohorts

English speakersN = 3,596

bilingual MDN = 170

no interpreterN = 141

interpreterN = 239

barrierN = 380

non-English speakersN = 550

included ptsN = 4,146

0

5

10

15

English speaking

InterpreterBilingual MD

No interpreter

0

5

10

15

0

10

20

30

120

130

140

150

Admission IVF bolus

Test cost Length of stay

% %

$ min

Non-English Speaking Patients(Versus English Speakers)

Bilingual MD No interpreter Interpreter

Admission (OR) 1.6 2.2* 1.2IVF Bolus (OR) 1.2 2.6* 1.7*Any Test (OR) .77 1.5* .73*

Test costs(English = $17) $18 $23* $20Test cost difference +6.7% +34%* +19%

Length of staydifference (min) +6.7 +3.8 +16*

*P<.05

Major Findings

1. Decisions more conservative andexpensive with barrier

2. Interpreters mitigated this, but longer ED stays

3. Bilingual MDs had similar effect, without changing length of stay

What the study didn’t prove

That these savings exceed the costs of providing interpreters

(i.e. that interpreters are “cost effective”)

Will telephonic interpretation help mitigate the premium?

Prospective Study

• Downtown Denver

• University pediatric ED

• ~45,000 visits/yr

• ~50% Latino

• ~10% LEP

Randomized Design

• Families asked at triage language of preference for

medical interview

• Even calendar days: “in-person” days

• Odd calendar days: “telephone” days (CyraCom)

• Pt’s got a bilingual provider if one was available,

regardless of calendar day

– “bilingual” providers verified

Outcome Measures

• Families surveyed 3-7 days after visit– investigator blinded to interpretation mode

• How do you rate:– your physician?– the interpretation?– overall satisfaction with the visit?

• Did you wish discharge instructions had been explained more clearly?

• What did they tell you was wrong with your child?

LEP familiesN=203

Bilingual provideravailable?

Yes No? Randomize

Bilingualprovider

N=42

In-personN=93

TelephonicN=68

Blinded, post-visit survey

x

0

10

20

30

40

50

60

70

80

90

100

satisfaction withprovider

overall satisfaction concordance withdiagnosis

clear instructions

telephonic

in-person

bilingual provider

Conclusions

• All 3 approaches seem to work well• Telephonic interpretation performed as well

as in-person interpreters and bilingual physicians

• Cost/benefit analysis of interpreter modalities need not include a “quality cost” for telephonic

Research Issue

• Challenges:– What outcomes should we look at?– defining and measuring costs

• costs of providing interpreters more evident than costs of not providing them

– costs to whom?