Use of Speech-to-Text Translation Resources to Address Communication Barriers in Patients With Hearing Loss: A Systematic Review.

OBJECTIVE: Patients with concomitant limited English proficiency (LEP) and hearing loss may experience communication barriers, not fully mitigated by traditional interpreter services. Although there is no clear consensus on the most reliable and optimal resources for these patients, speech-to-text (STT) applications with translation capability may bridge these barriers. We review the existing literature applying STT translation programs in clinical settings and identify commercially available STT translation resources to evaluate their prospective application in the otology setting. DATABASES REVIEWED: PubMed MEDLINE, Embase, and Web of Science. METHODS: A systematic review of English language peer-reviewed literature was conducted, examining STT translation in clinical settings. An additional search identifying STT software with translation capabilities was completed. RESULTS: Seven out of 591 unique citations met the inclusion criteria, and 29 unique STT translation applications were identified, supporting up to 140 languages. Stakeholders endorse positive perceptions of STT translation programs. Facilitators to implementation included time and cost feasibility, whereas barriers included risk of mistranslation and inability to assess accuracy. Ongoing machine-learning efforts are underway for developing and improving STT translation technologies, but there is paucity of literature evaluating their application in patients with hearing loss. CONCLUSIONS: Small studies have suggested an acceptable level of accuracy for STT translation programs as adjunctive to standard of care services. Further work should proactively address implementation challenges with special attention to use of these technologies for patients with concomitant LEP and HL, while supporting additional technological advancement for application of these technologies in otology practice.

Harnessing health information technology to promote equitable care for patients with limited English proficiency and complex care needs.

BACKGROUND: Patients with language barriers encounter healthcare disparities, which may be alleviated by leveraging interpreter skills to reduce cultural, language, and literacy barriers through improved bidirectional communication. Evidence supports the use of in-person interpreters, especially for interactions involving patients with complex care needs. Unfortunately, due to interpreter shortages and clinician underuse of interpreters, patients with language barriers frequently do not get the language services they need or are entitled to. Health information technologies (HIT), including artificial intelligence (AI), have the potential to streamline processes, prompt clinicians to utilize in-person interpreters, and support prioritization. METHODS: From May 1, 2023, to June 21, 2024, a single-center stepped wedge cluster randomized trial will be conducted within 35 units of Saint Marys Hospital & Methodist Hospital at Mayo Clinic in Rochester, Minnesota. The units include medical, surgical, trauma, and mixed ICUs and hospital floors that admit acute medical and surgical care patients as well as the emergency department (ED). The transitions between study phases will be initiated at 60-day intervals resulting in a 12-month study period. Units in the control group will receive standard care and rely on clinician initiative to request interpreter services. In the intervention group, the study team will generate a daily list of adult inpatients with language barriers, order the list based on their complexity scores (from highest to lowest), and share it with interpreter services, who will send a secure chat message to the bedside nurse. This engagement will be triggered by a predictive machine-learning algorithm based on a palliative care score, supplemented by other predictors of complexity including length of stay and level of care as well as procedures, events, and clinical notes. DISCUSSION: This pragmatic clinical trial approach will integrate a predictive machine-learning algorithm into a workflow process and evaluate the effectiveness of the intervention. We will compare the use of in-person interpreters and time to first interpreter use between the control and intervention groups. TRIAL REGISTRATION: NCT05860777. May 16, 2023.

Comparison of stroke process measures and clinical outcomes between English and Non-English preferring patients.

BACKGROUND: In the United States, limited English proficiency may reduce the quality of care and worsen outcomes after stroke. The aim was to compare stroke process measures and clinical outcomes between English preferring and non-English preferring stroke patients. METHODS/MATERIALS: This single-center retrospective cohort study evaluated patients from one United States hospital with acute ischemic stroke between July 2013 and June 2022. The primary outcomes were defect-free care, a composite of 7 stroke process measures, and independent ambulation at hospital discharge. Multivariate logistic regression models quantified the association between language preference and outcomes. Secondary outcomes included individual components of defect-free care, discharge modified Rankin scale, and discharge disposition. RESULTS: There were 4,030 patients with acute ischemic stroke identified, of which 2,965 were matched with language data from the electronic medical record. There were 373 non-English preferring patients, among which 76.9% preferred Spanish and 23.1% were non-English, non-Spanish preferring. In the multivariable model, there was no significant association between non-English preference and defect-free care (OR=0.64, 95% CI=0.26-1.59) or independent ambulation at discharge (OR=0.89, 95% CI=0.67-1.17). When compared to Spanish preferring patients, non-English, non-Spanish preferring patients had more severe strokes (P<0.001) but there was no difference in defect-free care or independent ambulation after adjustment. CONCLUSION: Our results suggest that process and clinical outcomes are similar regardless of language preference; although, our data are limited by small numbers of non-English, non-Spanish preferring patients. Additional research is needed among this population.

Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review.

BACKGROUND: Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations. QUESTIONS/PURPOSES: In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries? METHODS: On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed. RESULTS: There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores. CONCLUSION: Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses. LEVEL OF EVIDENCE: Level III, therapeutic study.

Examining the association between professional language interpreter services and intensive care unit utilization among patients with non-English language preference: Evidence from a large U.S. hospital.

OBJECTIVE: To examine the healthcare utilization of patients with non-English language preference (NELP) who utilized a professional language interpreter (PLI) in the intensive care unit (ICU) compared to similar patients with NELP who did not utilize a PLI in the ICU. METHODS: Single center cohort study of patients with NELP with at least one ICU admission a large academic medical center in the U.S. Midwest (1/1/2008-12/31/2022). The first model examined ICU length-of-stay (LOS) using a negative binomial and the second model examined whether a patient was readmitted to the ICU using a logistic regression with each model controlling for PLI utilization and covariates. RESULTS: Patients with NELP who utilized a PLI in the ICU had 0.87-days longer in the ICU (p < 0.01) and had a 46 % decreased odds of being readmitted to the ICU (p < 0.01) than a comparable patient with NELP who did not utilize a PLI in the ICU. CONCLUSION: Providing patients with NELP with access to a PLI in the ICU can improve patient outcomes and reduce language barriers. PRACTICE IMPLICATIONS: These results can provide the justification to potentially increase PLI staffing levels or increase the access to existing PLIs for more patients with NELP in ICUs.

Challenges in Assessment and Management of Postoperative Agitation and Delirium in a Stroke Patient with Limited English Proficiency: Case Report.

While Title VI of the Civil Rights Act of 1964 mandates use of interpreters for patients with limited English proficiency, significant disparities persist in intensive postsurgical care. We present the case of a 60-year-old Vietnamese-speaking man with a Type A aortic dissection requiring postoperative mechanical ventilation and stroke care. Despite use of a remote video interpreter, our language-discordant nursing and physician providers faced challenges in managing agitation and delirium and assessing neurological function. This case highlights the need for adequate interpretation equipment, linguistic diversity among providers, and interventions to promote and enable consistent certified and professional medical interpreter use.

Health Equities with Limited English Proficiency: A Review of the Literature.

Health equity exists when everyone has an equal opportunity to achieve their highest level of health. Effective communication is essential to ensure a therapeutic relationship. Patients with limited English proficiency (LEP) experience communication barriers, leading to poorer outcomes. Federal regulation requires hospitals to provide medically trained interpreters; however, this does not always occur. We identified 3 broad areas of research: communication barriers, outcomes, and costs. Findings highlight the challenges patients with LEP face in the health-care system, and the need for targeted interventions to enhance language access, improve cultural competence among health-care professionals, and ensure equitable outcomes for all.

Medical Interpretation for Emerging Populations: Building a Multi-Modal Interpretation Program for Pashto-Speakers at a Public Safety-Net Health System.

Limited English proficient patients are prone to adverse health care effects compared to English proficient patients, including decreased access to care, lower health literacy, and worse clinical outcomes. This report describes a multi-modal medical interpreter program at a safety-net health system designed for the emerging Afghan population in San Antonio, Texas.

Limited English proficiency, cardiovascular risk factors, cardiovascular disease, and in-hospital COVID-19 outcomes.

OBJECTIVES: Cardiovascular risk factors and history of cardiovascular disease are associated with greater morbidity and mortality in patients hospitalized with COVID-19. Limited English proficiency (LEP) has also been associated with worse outcomes in this setting, including requiring intensive care unit (ICU) level of care and in-hospital death. Whether non-English-language preference (NELP) modifies the association between cardiovascular risk factors or disease and outcomes in patients hospitalized with COVID-19 is unknown. STUDY DESIGN: Retrospective cohort study of adult patients admitted to a large New England health system between March 1 and December 31, 2020, who tested positive for COVID-19. NELP was defined as having a preferred language that was not English noted in the electronic health record. METHODS: Cardiovascular risk factors, history of cardiovascular disease, and NELP were related to the primary composite clinical outcome-death or ICU admission-using multivariable binary logistic regression adjusted for demographic and clinical characteristics. Interaction terms for NELP and model covariates were evaluated. RESULTS: Of 3582 patients hospitalized with COVID-19, 1024 (28.6%) had NELP; 812 (79.3%) of the patients with NELP received interpreter services. Death or ICU admission occurred in 794 (22.2%) of the hospitalized patients. NELP was not significantly associated with the primary composite outcome in unadjusted or adjusted analyses. In the adjusted analyses, only male gender, coronary artery disease, pulmonary circulatory disease, and liver disease significantly predicted the primary outcome. NELP did not modify the effect of these associations. CONCLUSIONS: NELP was not significantly associated with odds of death or ICU admission, nor did it modify the association between cardiovascular risk factors or history of cardiovascular disease and this composite outcome. Because most patients with NELP received interpreter services, these findings may support the role of such services in ensuring equitable outcomes.

Comparing Hospital Length of Stay Between Persons With LEP and English-Speaking Patients in a Large Rural Academic Medical Center.

BACKGROUND: Patients with limited English proficiency that are hospitalized without regular access to professional medical interpreters have a longer length of stay (LOS).1 The authors studied the difference in LOS between English-speaking patients and patients with limited English proficiency in New Hampshire's only academic trauma medical center. The authors also examined race, ethnicity, and distance of residence from hospital. METHODS: Retrospective data were queried from EPIC, the electronic medical record system used by the authors. Queried data focused on inpatient hospitalizations between January 1, 2019, and December 31, 2021. Patient primary language was grouped into English, Spanish, and other non-English language. RESULTS: Spanish-speaking patients live on average 39.6 miles farther from a hospital than English-speaking patients and have a 0.34 lower case mix index. After English, Spanish is the second-most frequently spoken language. Regression analyses found language to be a significant factor in LOS, LOS variance, and case mix index. DISCUSSION: A 2.34-day longer LOS for Spanish-speaking patients demonstrates an important health care disparity warranting further attention.

Patient Time Spent With Professional Medical Interpreters and the Care Experiences of Patients With Limited English Proficiency.

INTRODUCTION/OBJECTIVES: More time spent with interpreters may support clinician-patient communication for patients with limited English proficiency (LEP), especially when interpreter support before and after clinical encounters is considered. We assessed whether more time spent with interpreters is associated with better patient-reported experiences of clinician-patient communication and interpreter support among patients with LEP. METHODS: Patients with LEP (n = 338) were surveyed about their experiences with both the clinician and interpreter. Duration of interpreter support during the encounter (in min) and auxiliary time spent before and after encounters supporting patients (in min) were documented by interpreters. Multivariable linear regression models were estimated to assess the association of the time duration of interpreter support and patient experiences of (1) clinician-patient communication, and (2) interpreter support, controlling for patient and encounter characteristics. RESULTS: The average encounter duration was 47.7 min (standard deviation, SD = 25.1), the average auxiliary time was 43.8 min (SD = 16.4), and the average total interpreter time was 91.1 min (SD = 28.6). LEP patients reported better experiences of interpreter support with a mean score of 97.4 out of 100 (SD = 6.99) compared to clinician-patient communication, with a mean score of 93.7 out of 100 (SD = 14.1). In adjusted analyses, total patient time spent with an interpreter was associated with better patient experiences of clinician-patient communication (ß = 7.23, P < .01) when auxiliary time spent by interpreters supporting patients before and after the encounter was considered, but not when only the encounter time was considered. CONCLUSIONS: Longer duration of time spent with an interpreter was associated with better clinician-patient communication for patients with LEP when time spent with an interpreter before and after the clinician encounter is considered. Policymakers should consider reimbursing health care organizations for time interpreters spend providing patient navigation and other support beyond clinical encounters.

Who do patients depend on as they age and for what medical needs? An exploratory study of Chinese and Latino primary care patients.

BACKGROUND: As the U.S. population ages, family members increasingly act as informal caregivers, particularly for minority patients and those with limited English proficiency (LEP). However, physicians often do not identify or engage caregivers until there is a health crisis. This study aims to further our understanding of characteristics associated with having a caregiver present at a primary care visit, and better understand the specific roles family caregivers engage in to support older Chinese and Latino primary care patients. METHODS: Primary care patients were surveyed by telephone in a study of language access and communication. Participants included Chinese and Latino primary care patients (≥ 65 years old) from an academic general medicine practice. We asked patients if anyone was in the room with them during their most recent primary care visit (yes = caregiver accompanied). We asked about caregiving support for various needs, and examined associations of patient and visit characteristics with being accompanied, and frequency of caregiver support roles overall and by caregiver accompaniment. RESULTS: Among 906 participants, 80% preferred a non-English language, 64% were women, 88% had Medicare, and mean age was 76 years (range 65-97). 43% were accompanied to their most recent visit. Speaking English 'not at all' vs. 'very well' was associated with being caregiver accompanied (OR 3.5; 95% CI 1.3-9.7), as was older age ≥ 75 vs. 65-74 (OR 2.7; 95% CI 2.0-3.7). The most common roles being supported by caregivers included: transportation to medical appointments (63%), helping with medical decisions (60%), and talking with the doctor about the patient's medical care (54%). Even among unaccompanied patients, substantial proportions reported caregiver support with medical decisions (45%), talking with the doctor (33%), and medical needs at home (26%). CONCLUSIONS: Opportunities for physicians to engage caregivers who have active support roles may be missed, especially if those caregivers are not present at the visit. Future interventions should aim to help physicians identify which patients have caregivers and for what needs, so they may effectively engage caregivers before a health crisis occurs.

Heard but Excluded: A Language Manifesto.

This Viewpoint discusses dismantling language barriers via multipronged approaches grounded in innovation, human-centered design, and systems thinking in 3 key areas.

The Utility of Dot Phrases and SmartPhrases in Improving Physician Documentation of Interpreter Use.

Background: Patients with limited English proficiency (LEP) experience significant healthcare disparities. Clinicians are responsible for using and documenting their use of certified interpreters for patient encounters when appropriate. However, the data on interpreter use documentation in the emergency department (ED) is limited and variable. We sought to assess the effects of dot phrase and SmartPhrase implementation in an adult ED on the rates of documentation of interpreter use. Methods: We conducted an anonymous survey asking emergency clinicians to self-report documentation of interpreter use. We also retrospectively reviewed documentation of interpreter- services use in ED charts at three time points: 1) pre-intervention baseline; 2) post-implementation of a clinician-driven dot phrase shortcut; and 3) post-implementation of a SmartPhrase. Results: Most emergency clinicians reported using an interpreter "almost always" or "often." Our manual audit revealed that at baseline, interpreter use was documented in 35% of the initial clinician note, 4% of reassessments, and 0% of procedure notes; 52% of discharge instructions were written in the patients' preferred languages. After implementation of the dot phrase and SmartPhrase, respectively, rates of interpreter-use documentation improved to 43% and 97% of initial clinician notes, 9% and 6% of reassessments, and 5% and 35% of procedure notes, with 62% and 64% of discharge instructions written in the patients' preferred languages. Conclusion: There was a discrepancy between reported rates of interpreter use and interpreter-use documentation rates. The latter increased with the implementation of a clinician-driven dot phrase and then a SmartPhrase built into the notes. Ensuring accurate documentation of interpreter use is an impactful step in language equity for LEP patients.

Telehealth Experience Among Patients With Limited English Proficiency.

This cross-sectional study assesses the implication of patients' English language skills for telehealth use and visit experience.