Journal of General Internal Medicine

, Volume 32, Issue 8, pp 863–870 | Cite as

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

  • Jonathan S. Lee
  • Eliseo J. Pérez-Stable
  • Steven E. Gregorich
  • Michael H. Crawford
  • Adrienne Green
  • Jennifer Livaudais-Toman
  • Leah S. Karliner
Original Research

Abstract

Background

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.

Objective

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.

Design

Prospective, pre-post intervention implementation study using propensity analysis.

Subjects

Hospitalized patients undergoing invasive procedures on the cardiovascular, general surgery or orthopedic surgery floors.

Intervention

Installation of dual-handset interpreter phones at every bedside enabling 24-h immediate access to professional interpreters.

Main Measures

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.

Key Results

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%, p = 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).

Conclusions

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.

KEY WORDS

limited English proficiency informed consent medical interpreters physician-patient relations communication barriers language access 

Supplementary material

11606_2017_3983_MOESM1_ESM.docx (12 kb)
ESM 1(DOCX 12.4 kb)

References

  1. 1.
    Berg JW, Appelbaum PS. Informed consent: legal theory and clinical practice. 2nd ed. Oxford: Oxford University Press; 2001.Google Scholar
  2. 2.
    Jones JW, McCullough LB, Richman BW. A comprehensive primer of surgical informed consent. Surg Clin North Am. 2007;87(4):903–18. viii.CrossRefPubMedGoogle Scholar
  3. 3.
    U.S. Census Bureau. American Community Survey, 2015 American Community Survey 1-Year Estimates; using American FactFinder. http://factfinder2.census.gov. Accessed December 15, 2016.
  4. 4.
    Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care. 2002;40(1):52–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Karliner LS, Kim SE, Meltzer DO, Auerbach AD. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010;5(5):276–82.CrossRefPubMedGoogle Scholar
  6. 6.
    Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012;27(10):1294–9.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007;22(Suppl 2):324–30.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005;20(9):800–6.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Schenker Y, Wang F, Selig SJ, Ng R, Fernandez A. The impact of language barriers on documentation of informed consent at a hospital with on-site interpreter services. J Gen Intern Med. 2007;22(Suppl 2):294–9.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–54.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826–34.CrossRefPubMedGoogle Scholar
  13. 13.
    Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295–301.CrossRefPubMedGoogle Scholar
  14. 14.
    Street RL Jr. Analyzing communication in medical consultations. Do behavioral measures correspond to patients’ perceptions? Med Care. 1992;30(11):976–88.CrossRefPubMedGoogle Scholar
  15. 15.
    Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796–804.PubMedGoogle Scholar
  16. 16.
    Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423–33.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365–70.CrossRefPubMedGoogle Scholar
  18. 18.
    Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277(7):553–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Office for Civil Rights. Policy Guidance - Title VI Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency. U S Department of Health and Human Services. http://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/index.html. Accessed December 15, 2016.
  20. 20.
    Hunt LM, de Voogd KB. Are good intentions good enough? Informed consent without trained interpreters. J Gen Intern Med. 2007;22(5):598–605.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Patel DN, Wakeam E, Genoff M, Mujawar I, Ashley SW, Diamond LC. Preoperative consent for patients with limited English proficiency. J Surg Res. 2016;200(2):514–22.CrossRefPubMedGoogle Scholar
  22. 22.
    Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275(10):783–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Burbano O’Leary SC, Federico S, Hampers LC. The truth about language barriers: one residency program’s experience. Pediatrics. 2003;111(5 Pt 1):e569–73.CrossRefPubMedGoogle Scholar
  24. 24.
    Lee KC, Winickoff JP, Kim MK, et al. Resident physicians’ use of professional and nonprofessional interpreters: a national survey. JAMA. 2006;296(9):1050–3.CrossRefPubMedGoogle Scholar
  25. 25.
    Lopez L, Rodriguez F, Huerta D, Soukup J, Hicks L. Use of interpreters by physicians for hospitalized limited English proficient patients and its impact on patient outcomes. J Gen Intern Med. 2015;30(6):783–9.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Schenker Y, Perez-Stable EJ, Nickleach D, Karliner LS. Patterns of interpreter use for hospitalized patients with limited English proficiency. J Gen Intern Med. 2011;26(7):712–7.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256–62.CrossRefPubMedGoogle Scholar
  28. 28.
    Karliner LS, Pérez-Stable EJ, Gregorich SE. Convenient access to professional interpreters in the hospital decreases readmission rates and estimated hospital expenditures for patients with limited English proficiency. Med Care. 2016. doi:10.1097/MLR.0000000000000643.
  29. 29.
    Tuot DS, Lopez M, Miller C, Karliner LS. Impact of an easy-access telephonic interpreter program in the acute care setting: an evaluation of a quality improvement intervention. Jt Comm J Qual Patient Saf. 2012;38(2):81–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Karliner LS, Napoles-Springer AM, Schillinger D, Bibbins-Domingo K, Perez-Stable EJ. Identification of limited English proficient patients in clinical care. J Gen Intern Med. 2008;23(10):1555–60.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Borson S, Scanlan JM, Chen PJ, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51(10):1451–4.CrossRefPubMedGoogle Scholar
  32. 32.
    Chew LD, Griffin JM, Partin MR, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008;23(5):561–6.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Bollschweiler E, Apitzsch J, Obliers R, et al. Improving informed consent of surgical patients using a multimedia-based program? Results of a prospective randomized multicenter study of patients before cholecystectomy. Ann Surg. 2008;248(2):205–11.CrossRefPubMedGoogle Scholar
  34. 34.
    Heller L, Parker PA, Youssef A, Miller MJ. Interactive digital education aid in breast reconstruction. Plast Reconstr Surg. 2008;122(3):717–24.CrossRefPubMedGoogle Scholar
  35. 35.
    Paci E, Barneschi MG, Miccinesi G, Falchi S, Metrangolo L, Novelli GP. Informed consent and patient participation in the medical encounter: a list of questions for an informed choice about the type of anaesthesia. Eur J Anaesthesiol. 1999;16(3):160–5.CrossRefPubMedGoogle Scholar
  36. 36.
    Raynes-Greenow CH, Nassar N, Torvaldsen S, Trevena L, Roberts CL. Assisting informed decision making for labour analgesia: a randomised controlled trial of a decision aid for labour analgesia versus a pamphlet. BMC Pregnancy Childbirth. 2010;10:15.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Walker MS, Farria D, Schmidt M, et al. Educational intervention for women undergoing image-guided breast biopsy: results of a randomized clinical trial. Cancer Control. 2007;14(4):380–7.PubMedGoogle Scholar
  38. 38.
    Kinnersley P, Phillips K, Savage K, et al. Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. Cochrane Database Syst Rev. 2013;7, CD009445.Google Scholar
  39. 39.
    Karliner LS, Auerbach A, Napoles A, Schillinger D, Nickleach D, Perez-Stable EJ. Language barriers and understanding of hospital discharge instructions. Med Care. 2012;50(4):283–9.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Flores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012;60(5):545–53.CrossRefPubMedGoogle Scholar
  41. 41.
    Napoles AM, Santoyo-Olsson J, Karliner LS, Gregorich SE, Perez-Stable EJ. Inaccurate language interpretation and its clinical significance in the medical encounters of Spanish-speaking Latinos. Med Care. 2015;53(11):940–7.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Betancourt JR, Jacobs EA. Language barriers to informed consent and confidentiality: the impact on women’s health. J Am Med Womens Assoc. 2000;55(5):294–5.Google Scholar
  43. 43.
    Dohan D, Levintova M. Barriers beyond words: cancer, culture, and translation in a community of Russian speakers. J Gen Intern Med. 2007;22(Suppl 2):300–5.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Jacobs EA, Sadowski LS, Rathouz PJ. The impact of an enhanced interpreter service intervention on hospital costs and patient satisfaction. J Gen Intern Med. 2007;22(Suppl 2):306–11.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Sudore RL, Landefeld CS, Williams BA, Barnes DE, Lindquist K, Schillinger D. Use of a modified informed consent process among vulnerable patients: a descriptive study. J Gen Intern Med. 2006;21(8):867–73.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Diamond LC, Tuot DS, Karliner LS. The use of Spanish language skills by physicians and nurses: policy implications for teaching and testing. J Gen Intern Med. 2012;27(1):117–23.CrossRefPubMedGoogle Scholar
  47. 47.
    Maul L, Regenstein M, Andres E, Wright R, Wynia MK. Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter. Jt Comm J Qual Patient Saf. 2012;38(7):328–36.CrossRefPubMedGoogle Scholar
  48. 48.
    Diamond L, Grbic D, Genoff M, et al. Non-English-language proficiency of applicants to US residency programs. JAMA. 2014;312(22):2405–7.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Jonathan S. Lee
    • 1
    • 2
  • Eliseo J. Pérez-Stable
    • 3
  • Steven E. Gregorich
    • 1
    • 2
  • Michael H. Crawford
    • 4
  • Adrienne Green
    • 5
  • Jennifer Livaudais-Toman
    • 1
    • 2
  • Leah S. Karliner
    • 1
    • 2
  1. 1.Division of General Internal MedicineUniversity of California San FranciscoSan FranciscoUSA
  2. 2.Multiethnic Health Equity Research CenterUniversity of California San FranciscoSan FranciscoUSA
  3. 3.Office of the Director, National Institute of Minority Health and Health DisparitiesNational Institutes of HealthBethesdaUSA
  4. 4.Division of CardiologyUniversity of California San FranciscoSan FranciscoUSA
  5. 5.Division of Hospital MedicineUniversity of California San FranciscoSan FranciscoUSA

Personalised recommendations