In a new Canadian study of medical outcomes for older LEP people who had hip surgery, the Journal of the American Medical Association (JAMA) concludes:
“Patients with a non–English language preference served within English-dominant health care settings are at increased risk of adverse events that may be associated with communication barriers and inequitable access to care. In this retrospective cohort study of older patients undergoing hip fracture repair, non–English language preference was associated with longer length of stay, increased risk of delirium, and more frequent discharge to a nursing home.
These findings suggest inequities in hip fracture care for patients with a non–English language preference served in English-dominant health care settings.
Given that hip fractures remain one the leading causes of disability and mortality among older adults, there is a critical need to address these gaps to better serve linguistically diverse populations of older adults presenting with hip fracture. Increasing access to and use of effective professional interpretation, addressing cultural differences and implicit bias through staff training, and setting institutional standards for multilingual care are areas for improvement. “
The study analyzed the surgical experiences of more than 35,000 patients. The study measured surgical wait time and postoperative outcomes among older adults (66 years old and above), in Ontario, Canada, who underwent hip fracture surgery between January 1, 2017, and December 31, 2022. Analysis was conducted using linked administrative health care databases in Ontario, Canada, where health care delivery is provided primarily in English. Ontario is Canada’s most populous province and is home to a linguistically diverse population of more than 14.5 million residents, among whom 19.5%of adults report speaking a language other than English at home, comparable to non-English speakers in the US (21.5%)
According to JAMA, the Canadian study focused on various populations who may experience adverse health care outcomes because of income, race, and language.
As JAMA reports:
“Certain patients, including Asian or Black patients, males, and those with lower income or multiple comorbidities, may be more likely to experience surgical delays. Language discordance is another factor that may be associated with surgical delay as a result of deferral of surgical consent or postponed communication about symptoms and goals of care.
A systematic review of studies that included nearly 300 000 patients undergoing elective surgery found associations between English proficiency and multiple perioperative process-of-care outcomes, including delays in care, longer hospital admissions, and more discharges to a skilled nursing facility. A large retrospective study of patients with traumatic injuries similarly showed that individuals with limited English proficiency experienced increased length of stay and were more frequently discharged to rehabilitation or skilled nursing facilities. While language-related disparities have been well documented in these settings, little is known about processes of care or outcomes for non-English speakers with hip fracture, a common and costly event associated with significant morbidity and mortality in older adults. In this retrospective cohort study, we investigated the association of non-English language with surgical delay, postoperative complications, and discharge destination among older patients undergoing emergent hip fracture repair.”
In addition, the study found that hospitals in Canada and the United States must put more investment and effort into providing language access services, which are nationally required by law in the U.S. but not in Canada, where there is more of a province-by-province language access regiment without U.S.-comparable national legal mandates.
As JAMA notes:
“Our finding that patients who did not speak the dominant language of their health care system experienced longer lengths of stay has been consistently demonstrated across several surgical and medical settings in Canada and the US. [For example, see: Joo H, Fernández A, Wick EC, Moreno Lepe G, Manuel SP. “Association of language barriers with perioperative and surgical outcomes: a systematic review.” JAMA Netw Open. 2023; https://jama.jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2023.22743&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamanetworkopen.2024.48010
This provides additional evidence to incentivize hospital investment in interpretation services and the hiring of language-concordant clinicians. Despite increasing linguistic diversity, health care systems and staff often do not reflect the linguistic diversity of the communities they serve.
For example, 28% of the population speaks Spanish in California, where Spanish is the most underrepresented linguistic groups among physicians. In Canada, both English and French are official languages but just 15% of physicians outside of Quebec identify French as a language of competence. Institutions serving linguistically diverse communities should implement educational interventions, such as medical courses in other languages, and develop standards for language-concordant and culturally competent care.”
The Canadian study saliently reveals language-based disparities of care and recommends that hospitals devote more resources to language access for LEP patients. However, the 2024 study is but the latest in a long line of scholarly analyses, going back more than 20 years, that reached the same conclusion – lack of English language proficiency results in adverse health care outcomes for LEP patients.
Such studies include: Mass. General Hospital Disparities Solutions Center, 2013: Patients who said they were treated with disrespect on basis of race/ethnicity; “Promoting appropriate use of physicians’ non-English language skills in clinical care” American Medical Association, 2013; Cohen AL, Rivara F, Marcuse EK, McPhillips H, Davis R. “Are language barriers associated with serious medical events in hospitalized pediatric patients?” Pediatrics 2005;116(3):575-9.
Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. “Use and effectiveness of interpreters in an emergency department. Journal of the American Medical Association” 1996; Regenstein M, Huang J, West C, Trott J, Mead H, Andres E. “Improving the quality of language services delivery: Findings from a hospital quality improvement initiative.” Journal for Healthcare Quality 2012; 34 (2): 53-63; “A Failure to Communicate – Caring for Patients with Limited English Proficiency” – Dr. Robert Like, MD; and” Spanish-Speaking Parents’ Experiences Accessing Academic Medical Center Care”: Academic Pediatrics 2024
The Canadian study concludes by reaffirming the crucial, life-saving imperative of language access in health care, an admonition that should be universally understood and embraced today but unfortunately is not: “It is crucial that older patients who speak nondominant languages do not experience potentially preventable adverse outcomes and have the same opportunity for recovery and discharge home after hip fracture as those who speak dominant languages.”
© Bruce L. Adelson 2024. All Rights Reserved The material herein is educational and informational only. No legal advice is intended or conveyed.
Bruce L. Adelson, Esq., is nationally recognized for his compliance expertise. Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney. Mr. Adelson is a faculty member at the Georgetown University School of Medicine and University of Pittsburgh School of Law where he teaches organizational culture, implicit bias, cultural and civil rights awareness.
Mr. Adelson’s blogs are a Bromberg exclusive.