Results Summary and Professional Abstract

Results Summary

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Results Summary

What was the research about?

Compared with fluent English speakers, patients who speak limited English often receive lower quality health care and have worse health. Offering patients a better way to talk about their health in their preferred language may improve health and quality of care.

In this study, the research team compared patients who received care before and after their clinics started using the Language Access Systems Improvement program, or LASI. Before LASI, patients scheduled an in-person interpreter before their clinic visit. Or they could use the phone to talk to an interpreter on demand. When treating patients who spoke limited English, bilingual clinicians spoke in Cantonese, Mandarin, or Spanish based on their own comfort level.

After LASI, patients and clinicians could request on-demand interpreters via video. Clinicians could also take a test to be certified to use a non-English language with patients.

The research team looked at patient-clinician communication and health outcomes for patients who spoke limited English.

What were the results?

During clinical visits where clinicians and patients didn’t speak the same language, after LASI, patients were more likely to

• Use an interpreter
• Discuss exercise
• Remember discussing exercise and diet
• Complete lab tests within 30 days

LASI didn’t change whether patients

• Had a new prescription from their clinicians
• Knew if clinicians prescribed a new medicine
• Discussed diet during the visit
• Completed lab tests within 100 days
• Visited a referred specialist
• Had better control of their blood pressure, heart disease, or diabetes

Who was in the study?

To look at patient-clinician communication, the study included 1,029 clinic visits with adults at least 40 years old. All received care at a primary care practice in San Francisco, California. Of these adults, 73 percent were Chinese, and 27 percent were Latino. The average age was 70, and 67 percent were women.

To look at health outcomes, the study included 2,123 adults. All had at least one chronic health problem. Of these adults, 59 percent were Chinese, and 41 percent were Latino. The average age was 64, and 57 percent were women.

What did the research team do?

The research team surveyed patients by phone to ask about patient-clinician communication one week after their clinic visit. The team also looked at health records before and after LASI.

Patients and caregivers gave input on the study.

What were the limits of the study?

This study took place in one practice in one city. Findings may differ in other places.

Future research could look at more ways to improve health and health care for patients who speak limited English.

How can people use the results?

Health systems can use the results when looking at ways to support patients who speak limited English.

Professional Abstract

Professional Abstract

Objective

To evaluate the effectiveness of interpreter access for patients and language certification for clinicians on improving patient-clinician communication and clinical outcomes among Chinese and Latino adults

Study Design

Design Element	Description
Design	Quasi-experimental
Population	Communication: 1,029 primary care visits among Chinese and Latino adults at least 40 years old with limited English proficiency Clinical: 2,123 Chinese and Latino adults at least 18 years old with at least 1 chronic condition (hypertension, diabetes, or heart disease)
Interventions/ Comparators	Communication: partially language concordant or language discordant pre-LASI versus post-LASI clinic visits among adults with limited English proficiency Clinical: pre-LASI versus post-LASI comparison between adults with limited English proficiency and those who are English proficient
Outcomes	Communication: interpreter utilization, frequency of new medication prescribed at the visit, patient awareness of new medication prescription, frequency of diet and exercise discussions, patient awareness of diet and exercise discussions, completion of ordered lab tests within 30 days and within 100 days, completion of referral appointments Clinical: hypertension control, HbA1c control, anti-platelet or statin prescription
Timeframe	Communication: up to 1-week follow-up after clinic visits Clinical: up to 2-year follow up

Compared with fluent English speakers, patients who speak limited English often receive lower quality health care and often have worse health. This natural experiment examined whether the Language Access Systems Improvement (LASI) program improved patient-clinician communication and patients’ clinical outcomes. LASI included two initiatives in one health system in San Francisco: on-demand video medical interpretation services for patients and their clinicians and bilingual language certification for clinicians.

Before the LASI program, patients and their clinicians either scheduled an interpreter in advance for in-person services or could access telephone services on demand. When treating patients with limited English proficiency, bilingual clinicians spoke in Cantonese, Mandarin, or Spanish based on their self-reported ability. After LASI, patients and their clinicians could request on-demand interpreters via videoconferencing, and clinicians could take an oral proficiency test to be certified to use a non-English language with patients.

For communication outcomes, the study included 1,029 primary care visits. Of patients at these visits, 73% were Chinese, and 27% were Latino. The average age was 70, and 67% were female. Researchers surveyed patients by telephone and reviewed health records before and after LASI up to one week after patients’ clinical visits.

For clinical outcomes, the study included 2,123 Chinese and Latino adults with at least one chronic condition. Of these, 59% were Chinese, and 41% were Latino. The average age was 64, and 57% were female. Researchers reviewed patients’ health records before and after LASI to compare outcomes among Chinese and Latino adults who spoke limited English with those who were English proficient.

Patients and caregivers provided input on the study.

Results

Communication. Among partially language concordant or language discordant primary care visits with similar characteristics based on inverse probability weighted (IPW) propensity scores, the odds of professional interpreter use were higher post-LASI versus pre-LASI (IPW odds ratio [OR]=2.39; 95% confidence interval [CI]: 1.04, 5.48). Compared with pre-LASI, post-LASI patients were more likely to

• Have discussed exercise (IPW OR=2.04; 95% CI: 1.24, 3.36)
• Remember discussing exercise (IPW OR=5.02; 95% CI: 1.97, 12.8) and diet (IPW OR=5.94; 95% CI: 2.28, 15.5)
• Complete lab tests within 30 days (adjusted hazard ratio [aHR]=1.25; 95% CI: 1.0, 1.6)

Patients seeking care before and after LASI did not differ significantly in other communication outcomes.

Clinical. Compared with English-speaking patients, those who spoke limited English did not differ significantly in blood pressure control, HbA1C control, and statin or anti-platelet use pre- versus post-LASI.

Limitations

The study took place in one health system. Findings may differ in other locations.

Conclusions and Relevance

LASI was associated with increased professional interpreter use and increased patient awareness of diet and exercise discussions but not with improvements in clinical outcomes.

Future Research Needs

Future research could examine additional ways to improve clinical outcomes for patients with limited English proficiency.

More on this Project  

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

• The reviewers expressed concern about the researchers using an existing patient advisory committee for their engagement activities, when it was unclear how many people on that committee had experience with limited English proficiency. The researchers explained that while they used the existing patient advisory committee while developing the project proposal, once the study began they established the Advisory Collaboration on Language Access to better represent the needs of patients with limited English proficiency.
• The reviewers asked why the researchers excluded African Americans and other nonwhite patients as English-proficient controls in aim 2 of the project. The researchers said they only included the groups that they had previously specified in their protocol, including those with Chinese, Latino, and white ethnicity compared to non-English proficient Chinese and Spanish speakers. The researchers acknowledged that African Americans and other nonwhite, English- proficient groups are important subgroups to consider and may be included in future analyses.
• The reviewers asked about the measure used to assess health literacy. They suggested that future research should try to integrate the health literacy levels of family and friends who were present at visits and acted as interpreters or care partners. The researchers said they assessed health literacy assessed based on the answer to a single question: “How confident are you filling out medical forms by yourself?” The researchers noted that this question had been validated as an assessment for health literacy in a study published in 2008. 
• The reviewers asked about the use of video medical interpreting (VMI)—how  easy it was to work with, how VMI affected what patients and clinicians discussed, and whether technical problems with VMI interfered with rapport. The researchers responded that they did not have data on how often VMI technology malfunctioned during visits but said that the type of interpretation used did not significantly affect the patient-centeredness of visits. The researchers pointed out that in focus groups, patients and clinicians were largely happy with VMI.
• The reviewers wondered about the difficulty of certifying a clinician’s language skills, given that providers seemed reluctant to be tested on their language proficiency. The researchers said they used direct observation to account for provider reluctance, but that the direct observation tool they developed will require further study to establish its reliability and validity. The researchers noted that the implementation of the Language Access Systems Improvement program increased the overall use of interpretation services in visits.

Conflict of Interest Disclosures

View the COI disclosure form.

Project Details

Principal Investigator

Leah S. Karliner, MD, MAS

Project Status

Completed; PCORI Public and Professional Abstracts Posted

Project Title

Clinician Language Concordance and Interpreter Use: Impact of a Systems Intervention on Communication and Clinical Outcomes

Board Approval Date

April 2015

Project End Date

November 2020

Organization

University of California San Francisco

Year Awarded

2015

State

California

Year Completed

2020

Project Type

Research Project

Health Conditions  

Cardiovascular Diseases

Hypertension

Coronary or Ischemic Heart Disease

Multiple/Comorbid Chronic Conditions

Nutritional and Metabolic Disorders

Diabetes

Intervention Strategies

Other Health Services Interventions
Technology Interventions
Training and Education Interventions

Populations

Individuals with Multiple Chronic/co-morbid Conditions
Low Health Literacy/Numeracy
Low Income
Racial/Ethnic Minorities

Funding Announcement

Addressing Disparities

Project Budget

$2,581,630

Study Registration Information

HSRP20153367