Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters.

STUDY OBJECTIVE: To compare interpreter errors and their potential consequences in encounters with professional versus ad hoc versus no interpreters. METHODS: This was a cross-sectional error analysis of audiotaped emergency department (ED) visits during 30 months in the 2 largest pediatric EDs in Massachusetts. Participants were Spanish-speaking limited-English-proficient patients, caregivers, and their interpreters. Outcome measures included interpreter error numbers, types, and potential consequences. RESULTS: The 57 encounters included 20 with professional interpreters, 27 with ad hoc interpreters, and 10 with no interpreters; 1,884 interpreter errors were noted, and 18% had potential clinical consequences. The proportion of errors of potential consequence was significantly lower for professional (12%) versus ad hoc (22%) versus no interpreters (20%). Among professional interpreters, previous hours of interpreter training, but not years of experience, were significantly associated with error numbers, types, and potential consequences. The median errors by professional interpreters with greater than or equal to 100 hours of training was significantly lower, at 12, versus 33 for those with fewer than 100 hours of training. Those with greater than or equal to 100 hours of training committed significantly lower proportions of errors of potential consequence overall (2% versus 12%) and in every error category. CONCLUSION: Professional interpreters result in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters. Among professional interpreters, hours of previous training, but not years of experience, are associated with error numbers, types, and consequences. These findings suggest that requiring at least 100 hours of training for interpreters might have a major impact on reducing interpreter errors and their consequences in health care while improving quality and patient safety.

The Latino Health Insurance Program: a pilot intervention for enrolling Latino families in health insurance programs, East Boston, Massachusetts, 2006-2007.

BACKGROUND: Thirteen percent of Latinos in Massachusetts lack health insurance, the highest rate of any ethnic or racial group. Families without health insurance are more likely to be in poor or fair health, to lack a regular medical provider, and to not have visited a medical provider in the past year. CONTEXT: The Latino Health Insurance Program is designed as a response both to the high rate of uninsurance among Latinos in Boston and to the multiple obstacles that keep Latino parents from applying for insurance for their families. METHODS: In 2006, we designed and implemented a culturally competent model of health insurance outreach, education, enrollment and maintenance, and referral for primary care and social services for Latino families. CONSEQUENCES: Year 1 results of the Latino Health Insurance Program are promising. Six community members were hired and trained as case managers. A total of 230 children and adults were enrolled or re-enrolled in health insurance programs and received other needed services. Retention was near 100% after 1 year. INTERPRETATION: The Latino Health Insurance Program may serve as a model health insurance access program that can be adapted by community-based organizations and also can be incorporated into public agency programs for Latinos and other immigrant and minority groups. The program continues to serve East Boston residents and was expanded in 2008.

Limited english proficiency, primary language at home, and disparities in children's health care: how language barriers are measured matters.

BACKGROUND: Approximately 3.5 million U.S. schoolchildren are limited in English proficiency (LEP). Disparities in children's health and health care are associated with both LEP and speaking a language other than English at home, but prior research has not examined which of these two measures of language barriers is most useful in examining health care disparities. OBJECTIVES: Our objectives were to compare primary language spoken at home vs. parental LEP and their associations with health status, access to care, and use of health services in children. METHODS: We surveyed parents at urban community sites in Boston, asking 74 questions on children's health status, access to health care, and use of health services. RESULTS: Some 98% of the 1,100 participating children and families were of non-white race/ethnicity, 72% of parents were LEP, and 13 different primary languages were spoken at home. "Dose-response" relationships were observed between parental English proficiency and several child and parental sociodemographic features, including children's insurance coverage, parental educational attainment, citizenship and employment, and family income. Similar "dose-response" relationships were noted between the primary language spoken at home and many but not all of the same sociodemographic features. In multivariate analyses, LEP parents were associated with triple the odds of a child having fair/poor health status, double the odds of the child spending at least one day in bed for illness in the past year, and significantly greater odds of children not being brought in for needed medical care for six of nine access barriers to care. None of these findings were observed in analyses of the primary language spoken at home. Individual parental LEP categories were associated with different risks of adverse health status and outcomes. CONCLUSIONS: Parental LEP is superior to the primary language spoken at home as a measure of the impact of language barriers on children's health and health care. Individual parental LEP categories are associated with different risks of adverse outcomes in children's health and health care. Consistent data collection on parental English proficiency and referral of LEP parents to English classes by pediatric providers have the potential to contribute toward reduction and elimination of health care disparities for children of LEP parents.

How Medicaid and the State Children's Health Insurance Program can do a better job of insuring uninsured children: the perspectives of parents of uninsured Latino children.

BACKGROUND: Eight and a half million US children are uninsured, despite the 1997 enactment of the State Children's Health Insurance Program (SCHIP) with $39 billion in funding, and Latinos continue to be the most uninsured racial/ ethnic group, with 24% (3 million) uninsured. Why SCHIP and Medicaid have not been more successful insuring uninsured children is unclear. OBJECTIVE: To identify reasons why parents are unable to insure uninsured Latino children in a state where all low-income children are eligible for insurance. METHODS: Bilingual focus groups of parents of uninsured Latino children from Boston communities with the highest proportion of uninsured Latino children. RESULTS: The 30 parents interviewed in 6 focus groups had a mean age of 39 years; 63% never graduated high school and 33% were US citizens. The mean age of their children was 12 years, and the median annual family income was $9120. Parents reported 52 barriers to insuring children. Major obstacles included lack of knowledge about the application process and eligibility (especially misconceptions about work, welfare, and immigration), language barriers, immigration issues, income, hassles, pending decisions, family mobility, misinformation from insurance representatives (being told insurance is too expensive and parents must work), and system problems (including lost applications, discrimination, and excessive waits). Parents universally agreed case managers would be helpful in insuring uninsured children. CONCLUSIONS: Even in a state where all low-income children are eligible for health insurance, current SCHIP and Medicaid outreach and enrollment are not effectively reaching uninsured Latino children. Parents need better information about programs, eligibility, and the application process, and a more efficient, user-friendly system.

An evaluation of the linguistic and cultural validity of the Spanish language version of the children with special health care needs screener.

OBJECTIVES: The 2001 National Survey of Children with Special Health Care Needs (CSHCN) used the CSHCN Screener, a 5-item survey based tool, to identify children with special health care needs. The prevalence of special health care needs for Hispanic children was lower than that reported for all other ethnic and racial groups, with the exception of Asian children. To better understand the reasons for the lower prevalence rate, this study examined variations in CSHCN prevalence for Hispanic children according to whether parents responded to the National Survey of CSHCN screening interview in Spanish or English. The Spanish translation of the CSHCN Screener was further evaluated through a series of face-to-face interviews with parents with limited English proficiency (LEP). METHODS: The 2001 National Survey of CSHCN screened 372,174 children ages 0-17 years for special health care needs. Bivariate and multivariate analyses were conducted to examine the effects of interview language on the CSHCN prevalence rates for Hispanic children (n = 47,371). Using a standardized protocol, cognitive interviews were conducted in Spanish with 19 LEP parents to elicit their comprehension of and reactions to the screening questions. RESULTS: When parents were interviewed in English, 11.7% of Hispanic children were identified as CSHCN. When parents were interviewed in Spanish, 5.1% of Hispanic children were identified as CSHCN. Lower prevalence of the need for or use of prescription medications for chronic conditions made the largest contribution to the observed difference in CSHCN prevalence. Cognitive interviews with parents did not identify any linguistic or cultural deficiencies in the Spanish translation of the CSHCN Screener. Parents did express disinclination toward sharing details of their children's health in the context of a typical telephone survey.

Why are Latinos the most uninsured racial/ethnic group of US children? A community-based study of risk factors for and consequences of being an uninsured Latino child.

BACKGROUND: Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children. OBJECTIVE: [corrected] The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children. METHODS: A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance. RESULTS: Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the child's age, and the $4000 to $9999 and $15000 to $19999 family income quintiles were the only factors that were significantly associated with a child's being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. CONCLUSIONS: After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino children's high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

Keeping children with asthma out of hospitals: parents' and physicians' perspectives on how pediatric asthma hospitalizations can be prevented.

BACKGROUND: A total of 196,000 hospitalizations occur each year among the 9 million US children who have been diagnosed with asthma. Not enough is known about how to prevent pediatric asthma hospitalizations. OBJECTIVES: To identify the proportion of preventable pediatric asthma hospitalizations and how such hospitalizations might be prevented, according to parents and physicians of hospitalized children with asthma. METHODS: A cross-sectional survey was conducted of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of all children who were admitted for asthma to an urban hospital in a 14-month period. RESULTS: The 230 hospitalized children had a median age of 5 years; most were poor (median annual family income: 13,356 dollars), were nonwhite (93%), and had public (74%) or no (14%) health insurance. Compared with children who were hospitalized for other ambulatory care-sensitive conditions, hospitalized children with asthma were significantly more likely to be African American (70% vs 57%), to be older, and not to have made a physician visit or telephone contact before admission (52% vs 41%). Only 26% of parents said that their child's admission was preventable, compared with 38% of PCPs and 43% of IAPs. The proportion of asthma hospitalizations that were assessed as preventable varied according to the source or combination of sources, from 15% for agreement among all 3 sources to 54% as identified by any 1 of the 3 sources. PCPs (83%) and IAPs (67%) significantly more often than parents (44%) cited parent/patient-related reasons for how hospitalizations could have been prevented, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (27%) and IAPs (26%) significantly more often than PCPs (11%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age > or =11 years and no physician contact before the hospitalization were associated with approximately 2 times the odds of a preventable asthma hospitalization. CONCLUSIONS: The proportion of asthma hospitalizations assessed as preventable varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.

A randomized, controlled trial of the effectiveness of community-based case management in insuring uninsured Latino children.

BACKGROUND: Lack of health insurance adversely affects children's health. Eight million US children are uninsured, with Latinos being the racial/ethnic group at greatest risk for being uninsured. A randomized, controlled trial comparing the effectiveness of various public insurance strategies for insuring uninsured children has never been conducted. OBJECTIVE: To evaluate whether case managers are more effective than traditional methods in insuring uninsured Latino children. DESIGN: Randomized, controlled trial conducted from May 2002 to August 2004. SETTING AND PARTICIPANTS: A total of 275 uninsured Latino children and their parents were recruited from urban community sites in Boston. INTERVENTION: Uninsured children were assigned randomly to an intervention group with trained case managers or a control group that received traditional Medicaid and State Children's Health Insurance Program (SCHIP) outreach and enrollment. Case managers provided information on program eligibility, helped families complete insurance applications, acted as a family liaison with Medicaid/SCHIP, and assisted in maintaining coverage. MAIN OUTCOME MEASURES: Obtaining health insurance, coverage continuity, the time to obtain coverage, and parental satisfaction with the process of obtaining insurance for children were assessed. Subjects were contacted monthly for 1 year to monitor outcomes by a researcher blinded with respect to group assignment. RESULTS: One hundred thirty-nine subjects were assigned randomly to the intervention group and 136 to the control group. Intervention group children were significantly more likely to obtain health insurance (96% vs 57%) and had approximately 8 times the adjusted odds (odds ratio: 7.78; 95% confidence interval: 5.20-11.64) of obtaining insurance. Seventy-eight percent of intervention group children were insured continuously, compared with 30% of control group children. Intervention group children obtained insurance significantly faster (mean: 87.5 vs 134.8 days), and their parents were significantly more satisfied with the process of obtaining insurance. CONCLUSIONS: Community-based case managers are more effective than traditional Medicaid/SCHIP outreach and enrollment in insuring uninsured Latino children. Case management may be a useful mechanism to reduce the number of uninsured children, especially among high-risk populations.

Urban parents' knowledge and practices regarding managed care.

BACKGROUND: Managed care is the dominant form of health insurance in the United States, covering millions of children. Little is known about whether inner-city parents adequately understand managed care's complex definitions and rules. OBJECTIVE: The objective of this study was to examine managed care knowledge and practices among inner-city parents. METHODS: We conducted a cross-sectional survey of parents at inner-city community sites in Boston, including supermarkets, hair salons, and laundromats. Participants were asked 74 questions on access, insurance, and managed care. RESULTS: The 1100 participants were mostly poor, minority (82% Latino, 10% black) and covered by public health insurance. Although 55% of insured children were covered by managed care, 45% of the managed care-covered children's parents were unaware of their children's managed care coverage. When asked "What is managed care?," 88% of parents did not know it was a type of insurance, and 94% did not identify a specific feature; Latino parents were significantly more likely to provide a wrong/do not know answer to this question, and there was no significant association with whether the child was covered by managed care. Latino parents and parents with children not covered by managed care were significantly more likely to provide a wrong/do not know answer for all 11 questions about specific features of managed care, but the proportion of parents with managed care-covered children who gave wrong/do not know answers for these 11 questions ranged from 41% to 84%. More than half of parents gave wrong/do not know answers to 10 of the 11 questions about specific managed care features, regardless of whether their child was covered by managed care. Most parents reported that if their child were covered by managed care, they would bring the child to the emergency department without prior approval for 4 minor childhood illnesses. For each of these illnesses, at least two thirds of parents said that they would bring their child in without prior approval, ranging from 72% of parents for a child with diarrhea to 90% for a child with a sprained ankle. Latino ethnicity (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.2-3.1), having a nonmanaged care-covered child (OR, 2.3; 95% CI, 1.5-3.7), and having a managed care-covered child but being unaware of the managed care coverage (OR, 2.9; 95% CI, 1.6-5.2) were associated with greater adjusted odds of incorrect/do not know parental definitions of managed care. Low family income and limited English proficiency were consistently associated with a significantly higher adjusted odds of wrong/do not know answers about specific managed care features. In multivariable analyses, Latino parents were significantly more likely to bring a managed care-covered child with a minor illness to the emergency department without prior approval. CONCLUSIONS: Regardless of whether their children have managed care coverage, most inner-city parents interviewed in this study do not know what managed care is, have insufficient knowledge of managed care rules and practices, and believe that prior approval for emergency department visits for mild childhood illnesses is unnecessary. These findings indicate that many urban parents may need better, more comprehensible information about managed care, particularly those who are poor, Latino, and have limited English proficiency.

Keeping children out of hospitals: parents' and physicians' perspectives on how pediatric hospitalizations for ambulatory care-sensitive conditions can be avoided.

BACKGROUND: Avoidable hospitalization conditions (AHCs) are hospitalizations that potentially can be avoided with timely, appropriate outpatient care. The specific reasons for avoidability, and parents and physicians' perspectives on the proportion of actually avoidable pediatric AHCs, have not been examined adequately. OBJECTIVES: To identify how pediatric hospitalizations might be avoided, and to determine the proportion of avoidable AHCs according to parents and physicians of hospitalized children. METHODS: Cross-sectional survey of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of children who were admitted with AHCs to an urban hospital in a 14-month period. RESULTS: The 554 hospitalized children had a median age of 4 years; most were poor (median annual family income: 12,000 dollars), nonwhite (91%), and had public (73%) or no (16%) health insurance. The most frequent AHC diagnoses were asthma (43%), dehydration/gastroenteritis (16%), pneumonia (11%), seizure disorder (8%), and skin infections (8%). Only 25% of parents said that their child's admission was avoidable, compared with 29% of PCPs and 32% of IAPs. The proportion of AHC hospitalizations assessed as avoidable varied according to the source or combination of sources, from 13% for agreement among all 3 sources to 46% as identified by any 1 of the 3 sources. PCPs (71%) and IAPs (48%) significantly more often than parents (35%) cited parent/patient-related reasons for how hospitalizations could have been avoided, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (48%) significantly more often than PCPs (18%) and IAPs (37%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age >or=11 years, an asthma diagnosis, working poor family income, and having no health insurance were associated with approximately double to triple the odds of an avoidable hospitalization. CONCLUSIONS: The proportion of AHCs assessed as avoidable varies from 13% to 46%, depending on the source. Adolescents, children with asthma, children from working-poor families, and uninsured children are at greatest risk for avoidable hospitalizations. Many pediatric hospitalizations might be avoided if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers. Direct assessment by parents and physicians of hospitalized children can be an informative way to examine the proportion of avoidable pediatric hospitalizations and how they can be prevented.

Errors in medical interpretation and their potential clinical consequences in pediatric encounters.

BACKGROUND: About 19 million people in the United States are limited in English proficiency, but little is known about the frequency and potential clinical consequences of errors in medical interpretation. OBJECTIVES: To determine the frequency, categories, and potential clinical consequences of errors in medical interpretation. METHODS: During a 7-month period, we audiotaped and transcribed pediatric encounters in a hospital outpatient clinic in which a Spanish interpreter was used. For each transcript, we categorized each error in medical interpretation and determined whether errors had a potential clinical consequence. RESULTS: Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty-three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs 53%). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media. CONCLUSIONS: Errors in medical interpretation are common, averaging 31 per clinical encounter, and omissions are the most frequent type. Most errors have potential clinical consequences, and those committed by ad hoc interpreters are significantly more likely to have potential clinical consequences than those committed by hospital interpreters. Because errors by ad hoc interpreters are more likely to have potential clinical consequences, third-party reimbursement for trained interpreter services should be considered for patients with limited English proficiency.