Making the Case: Where’s the Evidence? Lou Hampers, MD, MBA Associate Professor of Pediatrics University of Colorado School of Medicine Section Chief, Pediatric Emergency Medicine

Excuses? Ad hoc interpreters “good enough” Ad hoc interpreters “good enough” Professional interpreters slow things down Professional interpreters slow things down Patients didn’t ask for/don’t want interpreters Patients didn’t ask for/don’t want interpreters ?HIPAA ?HIPAA Provider with “good enough” language skills Provider with “good enough” language skills Insurance won’t pay Insurance won’t pay “This is America, we speak English” “This is America, we speak English”

Loopholes? Requirements meant to be “reasonable” Requirements meant to be “reasonable” Valid considerations (per Federal guidelines) Valid considerations (per Federal guidelines) –LEP % in local population –Frequency of LEP encounters –Importance of service –Provider resources

Malpractice Case An adolescent Latino boy is found by an EMS crew with altered mental status. A caregiver uses the term "intoxicado" to describe the boy's condition. She intended to convey that the patient has been "nauseated". Healthcare personnel, without the aid of an interpreter, presume that the boy is "intoxicated". Immediate imaging of the patient's brain is not performed and the correct diagnosis of a ruptured aneurysm with intracranial hemorrhage is delayed. The outcome is irreversible brain damage and quadraplegia. The family is awarded $71 million.

The “Truth” Daily occurrence of unaddressed language barriers in the US is an open secret Daily occurrence of unaddressed language barriers in the US is an open secret Survey of pediatric residents at our Hospital Survey of pediatric residents at our Hospital –19 “proficient” in Spanish –40 “nonproficient” in Spanish 21 used their “Spanish” ‘often’ or ‘everyday’ 21 used their “Spanish” ‘often’ or ‘everyday’ 32 admitted “avoiding communication” with LEP families 32 admitted “avoiding communication” with LEP families Pediatrics 2003;5:e569

Opportunity costs Survey of residents at TCH Survey of residents at TCH 19 “proficient” in Spanish 19 “proficient” in Spanish 40 “nonproficient” in Spanish 40 “nonproficient” in Spanish Proficient residents estimated that they spent mean of 2.3 hrs/wk interpreting Proficient residents estimated that they spent mean of 2.3 hrs/wk interpreting –19 residents x 2.3 hrs = 44 hrs/wk Pediatrics 2003;5:e569

Quality Audiotapes of 13 LEP encounters Audiotapes of 13 LEP encounters –6 professional interpreters –7 ad hoc mean 19 important errors/encounter mean 19 important errors/encounter –omission, false fluency, substitution, edtiorialization, addition Ad hoc significantly more likely to make important errors Ad hoc significantly more likely to make important errors Pediatrics 2003;111:6

Interpreter Effects Prospective Cohorts Does this patient’s family speak English? Does this patient’s family speak English? Did this present a language barrier for you? Did this present a language barrier for you? Did you use an interpreter? Did you use an interpreter? Archives of Pediatrics and Adolescent Medicine 2002;156:1108

Cohorts

English speaking InterpreterBilingual MD No interpreter AdmissionIVF bolus Test cost Length of stay % % $min Archives of Pediatrics and Adolescent Medicine 2002;156:1108

Non-English Speaking Patients (Versus English Speakers) *P<.05 Archives of Pediatrics and Adolescent Medicine 2002;156:1108

Major Findings 1. Decisions more conservative and expensive with barrier 2. Interpreters mitigated this, but longer ED stays 3. Bilingual MDs had similar effect, without changing length of stay Archives of Pediatrics and Adolescent Medicine 2002;156:1108

What the study didn’t prove That these savings exceed the costs of providing interpreters (i.e. that interpreters are “cost effective”)

What do Providers Think? Study Objective: To explore views of providers participating in a randomized study To explore views of providers participating in a randomized study To compare provider views with LEP family opinions of these same services To compare provider views with LEP family opinions of these same services

Results (Providers’ Opinions)

Availability Availability of telephonic interpreters rated HIGHER than on-site interpreters

Randomized ED Design Families asked at triage language of preference for medical interview Families asked at triage language of preference for medical interview Randomized days: “in-person” vs “telephone” Randomized days: “in-person” vs “telephone” Pt’s got a bilingual provider if one was available, regardless of calendar day Pt’s got a bilingual provider if one was available, regardless of calendar day –“bilingual” providers verified Pediatrics 2010;125;e631

Outcome Measures Families surveyed after visit Families surveyed after visit –investigator blinded to interpretation mode How do you rate: How do you rate: –your physician? –the interpretation? –overall satisfaction with the visit? Did you wish discharge instructions had been explained more clearly? Did you wish discharge instructions had been explained more clearly? What did they tell you was wrong with your child? What did they tell you was wrong with your child? Pediatrics 2010;125;e631

Results LEP Family N=1201 Telephonic Interpreter N=406 In-Person Interpreter N=377 Bilingual Provider N=418

Satisfaction with Provider 97%98% 99% Pediatrics 2010;125;e631

Overall Satisfaction with Visit 89%90%90% Pediatrics 2010;125;e631

Concordance with Discharge Diagnosis 95%94%94% Pediatrics 2010;125;e631

Conclusions All 3 approaches seem to work well All 3 approaches seem to work well Telephonic interpretation performed as well as in- person interpreters and bilingual physicians Telephonic interpretation performed as well as in- person interpreters and bilingual physicians Cost/benefit analysis of interpreter modalities need not include a “quality cost” for telephonic Cost/benefit analysis of interpreter modalities need not include a “quality cost” for telephonic Pediatrics 2010;125;e631