Specialty Care Utilization Among Adults with Limited English Proficiency.

BACKGROUND: People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. OBJECTIVE: To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. DESIGN: Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. PARTICIPANTS: 149,611 survey respondents aged 18 and older. EXPOSURE: LEP, defined as taking the survey in a language other than English. MAIN MEASURES: Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. KEY RESULTS: Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). CONCLUSIONS: Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.

Unique Breast Cancer Screening Disparities in a Safety-Net Health System.

INTRODUCTION: Breast cancer screening (BCS) disparities leave historically underserved groups more vulnerable to adverse outcomes. This study explores granular associations between BCS and patient sociodemographic factors in a large urban safety-net health system. METHODS: A retrospective review among female patients ages 50-74 within an urban safety-net health system was conducted in 2019. All patients had a primary care visit in the past 2 years. Multiple patient health and sociodemographic characteristics were reviewed, as well as provider gender and specialty. Bivariate analyses and multivariable logistic regression were performed in 2022. RESULTS: The BCS rate among 11,962 women was 69.7%. Over half of patients were non-White (63.6%) and had public insurance (72.3%). Patients with limited English proficiency made up 44.3% of the cohort. Compared to their sociodemographic counterparts, patients with White race, English proficiency, and Medicare insurance had the lowest rates of BCS. Serious mental illness and substance use disorder were associated with lower odds of BCS. In multivariable analysis, when using White race and English speakers as a reference, most other races (Black, Hispanic, and Other) and languages (Spanish, Portuguese, and Other) had significantly higher odds of screening ranging from 8% to 63% higher, except Asian race and Haitian Creole language. Female (versus male) and internal medicine-trained providers were associated with higher screening odds. CONCLUSIONS: Multiple unique variables contribute to BCS disparities, influenced by patient and health system factors. Defining and understanding the interplay of these variables can guide policymaking and identify avenues to improve BCS for vulnerable or traditionally under-resourced populations.

Advance Directive Completion Among Black Adults Within a Community-Based Integrated Health Care System.

ObjectivesThe study was conducted to estimate the prevalence of advance directive (AD) completion among Black adults vs non-Hispanic White adults within Kaiser Permanente Northern California integrated health system that includes access to outpatient advance care planning (ACP) specialists and to identify medical services utilization patterns and societal factors that could influence ACP engagement. DesignThe study was carried out through retrospective analysis of electronic health record data of active Kaiser Permanente Northern California members from January 1, 2013 to December 31, 2017, who were age 55 and older, and represented 572,466 active members, of which 11.7% were Black adults. The primary objective was AD completion comparing Black adults to non-Hispanic White adults. Demographic data included age, sex, comorbidities (Charlson comorbidity score ≥ 3) and medical services utilization (inpatient, outpatient, and emergency department [ED] use). Sociodemographic data derived from census data that include census block demographics and head of household educational attainment were utilized. ResultsBlack adults were younger, but had a higher burden of comorbidities (Charlson comorbidity score ≥ 3, 25.3% vs 19.3%) and were more likely to have multiple ED visits (6.7% vs 3.3%) compared to non-Hispanic White adults. The crude AD completion rate was lower among Black adults (10.0% vs 20.3%), and after adjusting for age and health system service area, the difference remained largely unchanged (11.7% vs 20.3%) compared to non-Hispanic White adults. ConclusionsAmong Kaiser Permanente Northern California members with access to outpatient ACP specialists, Black adults were only half as likely to complete an AD. This disparity was only slightly attenuated when standardized for age and health system service area. In addition, Black adults were also less likely to use outpatient services and more likely to use ED services.

Assessment of Immigrants' Premium and Tax Payments for Health Care and the Costs of Their Care.

Importance: Some worry that immigrants burden the US economy and particularly the health care system. However, no analyses to date have assessed whether immigrants' payments for premiums and taxes that fund health care programs exceed third-party payers' expenditures on their behalf. Objective: To assess immigrants' net financial contributions to US health care programs. Design, Setting, and Participants: This cross-sectional analysis used 2017 data from the Medical Expenditure Panel Survey (MEPS) and the Current Population Survey (CPS) and 2014 to 2018 data from the American Community Survey. The main analyses used data from the calendar year 2017. Data from the calendar years 2012 to 2016 were also reported. Data were analyzed from June 15, 2020, to August 14, 2022. Participants comprised 210 669 community-dwelling respondents to the MEPS and CPS (main analysis) and nursing home residents who were included in the American Community Survey (additional analysis). Exposures: Citizenship and immigration status. Main Outcomes and Measures: Total and per capita payments for premiums and taxes that fund health care as well as third-party payers' expenditures for health care in 2018 US dollars. Results: Among 210 669 participants, 51.0% were female, 18.3% were Hispanic, 12.3% were non-Hispanic Black, 60.3% were non-Hispanic White, and 9.2% were of other races and/or ethnicities. A total of 180 084 participants were respondents to the 2018 CPS, and 30 585 were respondents to the 2017 MEPS. Among the 180 084 CPS respondents, immigrants accounted for 14.1% (weighted to be nationally representative), with the subgroup of citizen immigrants accounting for 6.8%, documented noncitizen immigrants accounting for 3.7%, and undocumented immigrants accounting for 3.6%; US-born citizens constituted 85.9% of the population. Relative to US-born citizens, immigrants were more often age 18 to 64 years (79.6% vs 58.3%), of Hispanic ethnicity (45.0% vs 14.0%), and uninsured (16.8% vs 7.4%); similar percentages (51.4% vs 50.9%) were female. US-born citizens vs immigrants paid similar amounts in premiums and taxes ($6269 per capita [95% CI, $6185-$6353 per capita] vs $6345 per capita [95% CI, $6220-$6470 per capita]). However, third-party expenditures for immigrants' health care ($5061 per capita; 95% CI, $4673-$5448 per capita) were lower than their expenditures for the care of US-born citizens ($6511 per capita; 95% CI, $6275-$6747 per capita). Immigrants, in general, paid significantly more per person (net contribution, $1284; 95% CI, $876-$1691) than was paid on their behalf. Most of this surplus was accounted for by undocumented immigrants, whose contributions exceeded their expenditures by $4418 per person (95% CI, $4047-$4789 per person). US-born citizens collectively paid $67.2 billion (95% CI, -$2.3 to $136.3 billion) less in premiums and taxes than third-party payers paid for their care. This deficit was mostly offset by the $58.3 billion (95% CI, $39.8-$76.8 billion) net surplus of payments from immigrants, 89% of which ($51.9 billion; 95% CI, $47.5-$56.3 billion) was attributable to undocumented immigrants. Conclusions and Relevance: In this study, immigrants appeared to subsidize the health care of other US residents, suggesting that concerns that immigrants deplete health care resources may be unfounded.

Health Care Spending And Use Among Hispanic Adults With And Without Limited English Proficiency, 1999-2018.

One in seven people in the US speak Spanish at home, and twenty-five million people in the US have limited English proficiency. Using nationally representative data from the Medical Expenditure Panel Survey, we compare health care spending for and health care use by Hispanics adults with limited English proficiency with spending for and use by English-proficient Hispanic and non-Hispanic adults. During 2014-18 mean annual per capita expenditures were $1,463 (35 percent) lower for Hispanic adults with limited English proficiency than for Hispanic adults who were English proficient, after adjustment for respondents' characteristics. Hispanic adults with limited English proficiency also made fewer outpatient and emergency department visits, had fewer inpatient days, and received fewer prescription medications than Hispanic adults who were English proficient. Health care spending gaps between Hispanic adults with limited English proficiency and non-Hispanic adults with English proficiency widened between 1999 and 2018. These language-based gaps in spending and use raise concern that language barriers may be obstructing access to care, resulting in underuse of medical services by adults with limited English proficiency.

U.S. medical school curricula on working with medical interpreters and/or patients with limited English proficiency.

PURPOSE: The United States has an increasing population of individuals with limited English proficiency (LEP). Language access is a right for individuals with LEP in the health care system. As such, it is important for medical providers to be appropriately trained to work with individuals with LEP. Therefore, the purpose of this study was to describe curricula offered by United States medical schools to teach medical students to work with medical interpreters and/or patients with LEP. METHODS: An electronic survey was sent in March 2017 to administration at the 147 Liaison Committee on Medical Education® accredited medical schools as of November 7, 2016. The survey consisted of the following question: "As part of your medical school's curriculum, are students provided specific instruction addressing how to work with medical interpreters and/or patients with limited English proficiency (LEP)?" with different follow-up questions for schools that responded "Yes" vs "No". RESULTS: Responses were received from 26% (38/147) of medical schools. Among schools responding to the survey, 76% (29/38) offered a curriculum that provides instruction of how to work with medical interpreters and/or patients with LEP. Of schools that provide instruction, teaching methods included didactic sessions (34% [10/29]) and standardized patient experiences (34% [10/29]). In addition, 76% (22/29) offer training in the first 2 years of medical school and 28% (8/29) offer training in the third and fourth years of the curriculum. Sixty-two percent (18/29) of respondents that offered a formal curriculum have been administering a formal curriculum for ≤10 years. CONCLUSION: The majority of the responding medical schools offer formal instruction of how to work with medical interpreters and/or patients with LEP. Most schools started this type of instruction in the last 10 years with most instruction occurring in the first 2 years of an undergraduate medical curriculum.