I’ve noticed a theme in my clinic since I started practicing medicine: when a patient understands what is being said about their care, treatment, and services, they’re more likely to fulfill critical health care responsibilities. No one should be surprised by this, but as our nation and hospitals increase in diversity, the issue of health care equality for LEP (limited English proficiency) patients is becoming more pronounced.
Today, this population of Americans is estimated to be approximately 8% (age five years or older) of the nation. However, health care recipients with limited English proficiency (LEP) receive, on average, lower quality of health care and clinical outcomes than those who are English-proficient. As our country attempts to live up to its promise of providing equal opportunity for all races and cultures, we must face the issue of treatment disparity for LEP patients.
Some statistics about languages in the United States:
- Top 10 most common languages spoken in the U.S. (in order): English, Spanish, French, Chinese, German, Tagalog, Vietnamese, Korean, Italian, Russian
- Largest number of languages spoken by state: California (207), New York (169), Washington (163), Texas (145), Oregon (138), Pennsylvania (135), Florida (134), Illinois (132), New Jersey (130), Arizona (129)
- Counties that have 100 or more languages spoken: Los Angeles County, California (135), King County, Washington (118), Maricopa County, Arizona (110), San Diego County, California (110), Cook County, Illinois (109), Queens County, New York (105), Santa Clara County, California (104), Alameda County, California (101), and Orange County, California (100)
Despite legislation and attempts at improving care quality for LEP patients, most research surrounding LEP patient outcomes decidedly shows that this population receives the short end of the stick when it comes to health care.
- One study analyzed over 1,000 adverse-incident reports from six Joint Commission-accredited hospitals for LEP and English-speaking patients and found that 49% of LEP patients experienced physical harm versus 29.5% of English-speaking patients.
- LEP patients are 25% less likely to have received full documentation that provides informed consent before they undergo invasive procedures and suffer from higher rates of medical errors and worse clinical outcomes than English-proficient patients.
- Lower quality of care measurements for LEP patients include greater risk of infection, longer hospital stays, and a higher chance of readmission for chronic conditions.
Unfortunately, despite clear disparities in health care quality, LEP patients must contend with language barriers that have largely been treated as either unavoidable or not worth the cost of fully addressing.
Title VI of the Civil Rights Act requires health care organizations receiving federal funds to provide competent interpreter services when needed.
While it seems effective on paper, this practice may not be enforced for nearly half of all LEP patients. For example, one study from 2011 found that 43% of hospitalized patients with LEP had communicated without an interpreter present during admission, and 40% had communicated without an interpreter present after admission. In other words, while some organizations may “provide” competent interpreter services, that does not necessarily mean they utilize them in every scenario.
One reason I’ve noticed that health care providers do not utilize interpreter services is faith in using family members or friends as interpreters in a pinch. However, this method of communication is rife with the potential for errors. Another reason is the belief that clinicians may be able to get by with just basic competency and language understanding. However, this approach also increases patient risk.
Fortunately, The Joint Commission has played an instrumental role in ensuring that LEP patients receive more focused care. In 2012, The Joint Commission issued a new set of standards on patient-centered communication, emphasizing the importance of focusing on LEP, cultural competency, and patient-centered care. Additionally, many individual federal programs, states, and localities also have provisions requiring language services for LEP individuals.
Numerous studies have shown that language concordance improves patient satisfaction, engagement, perceived understanding, utilization of preventative services, and clinical outcomes. Apprehensions about the cost-efficiency of paying for and utilizing interpreter services may be unfounded, as one study found that, compared with English-speaking patients, patients who used the interpreter services received significantly more recommended preventive services, made more office visits and had more prescriptions written and filled.
As health care providers, we have a key role in fostering a supportive culture for the safety of diverse patient populations. Here are steps that health care providers can take in order to improve LEP and ESL patient outcomes:
- Make interpreter services easy to use (train staff to improve clinic flow, etc.).
- Enforce clear rules about using interpreter services and track enforcement openly.
- Share lessons learned from patient safety events with all staff to help build an institutional culture sensitive to issues that affect LEP patients.
- Ensure that clinicians communicate effectively about errors with patients and their families.
- Send a strong message to medical students and staff that good communication with LEP patients is vital to quality clinical practice.
- Staff members should only be used as interpreters if they are fluent in the necessary language and if interpretation services are among the designated duties of their position.
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