The Effect of Professional Medical
Interpretation in the Pediatric ED
Louis Hampers, MD, MBA
Medical Director, Emergency Department
Associate Professor of Pediatrics
University 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
Design
Prospective
Inclusion:
T > 38.5oC
2 mo to 10 yrs
+
or
vomiting or diarrhea
Clinical appearance recorded
Design
Prospective Cohorts
• Does this patient’s family speak English?
• Did this present a language barrier for you?
• Did you use an interpreter?
Cohorts
included pts
N = 4,146
English speakers
N = 3,596
non-English speakers
N = 550
bilingual MD
N = 170
barrier
N = 380
no interpreter
N = 141
interpreter
N = 239
15
10
%
$
15
Admission
10
%
5
5
0
0
30
150
20
Test cost
min
IVF bolus
140
10
130
0
120
Length of stay
English speaking
No interpreter
Bilingual MD
Interpreter
Non-English Speaking Patients
(Versus English Speakers)
Bilingual MD
No interpreter Interpreter
Admission (OR)
IVF Bolus (OR)
Any Test (OR)
1.6
1.2
.77
2.2*
2.6*
1.5*
1.2
1.7*
.73*
Test costs
(English = $17)
Test cost difference
$18
+6.7%
$23*
+34%*
$20
+19%
Length of stay
difference (min)
+6.7
+3.8
+16*
*P<.05
Major Findings
1.
Decisions more conservative and
expensive 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 families
N=203
Bilingual provider
available?
Yes
Bilingual
provider
N=42
No?
Randomize
In-person
N=93
Blinded, post-visit survey
Telephonic
N=68
telephonic x
in-person
bilingual provider
100
90
80
70
60
50
40
30
20
10
0
satisfaction with overall satisfaction concordance with clear instructions
provider
diagnosis
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?