How do low-income limited English proficient adults use ambulatory health services when they have health insurance and access to interpreters? Elinor A. Graham MD, MPH Troy A. Jacobs, MD, MPH Tao Sheng Kwan-Gett, MD, MPH Jane Cover, PhD candidate, MPH University of Washington Seattle, Washington

Limited English Proficient (LEP) Populations 11 million persons in the 2000 census LEP less health insurance Language is barrier No information on utilization of LEP vs English when SES & health insurance is the same and language barriers are reduced

Study Population Enrolled in Medicaid Managed Care At least one month, 7/97-7/99 Used UW health care system during study period Assigned to primary care clinic Ages subjects 12,617 ambulatory visits

Utilization Data Retrospective / Administrative data sets Use data from billing Visits only included if occurred during months enrolled in managed care Visit data expressed as visits per member month enrolled (VMME) Hospitalization: “None” vs “Any”

English Proficiency LEP: used interpreter services at least once during the two year study period English speaker if no record of interpreter use

Confounder Variables Age Gender Months enrolled in Medicaid managed care Disease groupings from visit diagnosis

12 Disease Groupings : Captured 74% of Ambulatory Visits Acute Respiratory Illness Atopic Disease Back Pain Birth Control Chronic Disease (Cancer, diabetes, HBP) GI Disease Headache Injury Pregnancy Preventive Psychosocial Urinary Tract Infection

Statistical Analysis Analyses for total population and females only Proportions and VMME: chi squared and t-tests Logistic regression modeled relationship between risk markers and site-specific visits Adjusted for clustering

Demographic Results 567 (33%) LEP & 1162 English speakers LEP compared to English speakers: Less likely female (80 vs 91%) Older: mean age 38 yrs vs 32 yrs yr age group: 26 vs 7% Of LEP, 46% East African and 43% Asian

Medicaid Managed Care Enrollment LEP enrolled longer and more continuously than English speakers mean: 18.8 vs 15.8 months 24 vs 14% enrolled continuously for 24 mos 15 vs 26% enrolled 6 months or less

Ambulatory Care Utilization Visit SiteLEP Speakers VMME LEP Speakers % who visited site English Speakers VMME English Speakers % who visited site Primary Care 0.515*** 6.2 visits/yr 95.0*** visits/yr 82.2 Specialty Care 0.245* 2.9 visits/yr 60.4*** visits/yr 49.8 ED visits/yr 30.8*** visits/yr 46.5

Disease Burden: LEP vs English LEP: significantly higher VMME for chronic disease (.311vs.178) No other disease groups showed significant differences in VMME Significantly higher % of LEP speakers made visits for: Preventive Acute respiratory Atopic disease Headache Back pain GI complaints Birth Control

Disease Groups: Pregnancy Diagnosis group associated with largest number of visits 1781 ambulatory visits 432 women had diagnosis during the 2 year period Mean age: LEP 29 yrs/ English 26 yrs.

Care Site Use: Women with Pregnancy Diagnosis LEPEnglish VMME Primary Care97%*88%* Specialty Care9%***23%*** ED6%7% Hospitalized54%61%

Any Hospitalization 344 subjects hospitalized during the 2 year study period: only 10 male During the study period, of the 334 women hospitalized: 255 had normal pregnancy diagnosis 172 had complicated pregnancy diagnosis

Any Hospitalization LEP Subjects 16% Hospitalized 2 subjects no ambulatory visits More VMME to primary care, less to ED compared to non hospitalized LEP subjects English Speakers 22% Hospitalized 24 subjects no ambulatory visits Less VMME to primary care, ED,& specialty compared to non-hospitalized English speakers

Ethnic Group Use of Care Sites VMME East African Asian Primary Care95% Specialty Care62%57% ED42%***18%*** Hospitalized23%***8%*** Women: Pregnancy Dx37%***19%***

Multivariant Analysis LEP 94% more likely to make primary care visit LEP 78% less likely to make ED visit Specialty visits and hospitalization not significantly different from English Same patterns when females only analyzed

Risk Markers for Primary Care Visit Risk MarkerOdds Ratio (95% CI) Age0.98 ( ) LEP1.94 ( ) Female1.05 ( ) Member mos enrolled1.00 ( ) Preventive Visit9.36 ( ) Chronic Disease Visit1.47 ( ) Injury Visit0.21 ( ) Atopic Disease Visit1.48 ( ) Respiratory Illness1.03 ( )

Risk markers for Specialty Care Visit Risk MarkerOdds Ratio (95% CI) Age1.04 ( ) LEP0.82 ( ) Female1.00 ( ) Member months enrolled1.00 ( ) Preventive Visit0.59 ( ) Chronic Disease Visit0.87 ( ) Injury Visit1.06 ( ) Atopic Disease Visit0.71 ( ) Respiratory Illness0.25 ( )

Risk markers for Emergency Visit Risk MarkerOdds Ratio (95% CI) Age0.98 ( ) LEP0.32 ( ) Female0.93 ( ) Member months enrolled1.00 ( ) Preventive Visit0.26 ( ) Chronic Disease Visit0.28 ( ) Injury Visit6.61 ( ) Atopic Disease Visit0.69 ( ) Respiratory Illness3.06 ( )

Risk markers for Hospitalization Risk MarkerOdds Ratio (95% CI) Age0.95 ( ) LEP0.76 ( ) Female1.71 ( ) Member months enrolled0.99 ( ) Preventive Visit0.57 ( ) Chronic Disease Visit0.53 ( ) Injury Visit0.46 ( ) Atopic Disease Visit0.41 ( ) Respiratory Illness0.53 ( )

Risk markers for Females : Primary Care Risk MarkerOR (95% CI) Age1.00 ( ) LEP1.90 ( ) Member Months Enrolled1.01 ( ) Preventive Visit11.71 ( ) Chronic Disease Visit1.14 ( ) Injury Visit0.25 ( ) Atopic Disease Visit1.50 ( ) Respiratory Illness Visit1.09 ( ) Pregnancy12.28 ( ) Complicated Pregnancy0.31 ( ) Pregnancy X LEP0.99 ( )

Risk Markers for Females : Specialty Visits Risk MarkerOR (95% CI) Age1.02 ( ) LEP0.91 ( ) Member Months Enrolled0.99 ( ) Preventive Visit0.05 ( ) Chronic Disease Visit1.20 ( ) Injury Visit0.94 ( ) Atopic Disease Visit0.71 ( ) Respiratory Illness Visit0.24 ( ) Pregnancy0.20 ( ) Complicated Pregnancy2.28 ( ) Pregnancy X LEP0.25 ( )

Risk Markers for Females : ED Visits Risk MarkerOR (95% CI) Age0.97 ( ) LEP0.30 ( ) Member Months Enrolled0.99 ( ) Preventive Visit0.22 ( ) Chronic Disease Visit0.26 ( ) Injury Visit5.67 ( ) Atopic Disease Visit0.70 ( ) Respiratory Illness Visit2.89 ( ) Pregnancy0.04 ( ) Complicated Pregnancy5.50 ( ) Pregnancy X LEP5.74 ( )

Risk Markers for Females : Hospitalization Risk MarkerOR (95% CI) Age0.97 ( ) LEP0.75 ( ) Member Months Enrolled1.01 ( ) Preventive Visit0.65 ( ) Chronic Disease Visit0.67 ( ) Injury Visit0.68 ( ) Atopic Disease Visit0.48 ( ) Respiratory Illness Visit0.69 ( ) Pregnancy7.30 ( ) Complicated Pregnancy0.78 ( ) Pregnancy X LEP0.84 ( )

Demographic and Medicaid Enrollment Differences Intact refugee and immigrant families = Medicaid coverage for more males and older adults Nine months of federal Medicaid coverage for refugees at time of study Social support systems helped immigrants and refugees stay enrolled in Medicaid

Utilization Patterns Low income LEP patients were more likely to use UW system as a primary care home English speakers had more options for care and may use UW system primarily for pregnancy and delivery Medically trained interpreters act as advocates for LEP and enable use of primary care and referrals

Limitations Retrospective/administrative data set Hospitalization data could only be evaluated as “none” or “any” LEP based on interpreter use, not on patient report or tests of English proficiency Data represents users of the system Acculturation not evaluated

Conclusions When language & health insurance barriers are reduced, low income LEP patients compared to English speaking: Are enrolled longer and more consistently in Medicaid Use more primary care & less ED Establish a primary care home

Funding for Study University of Washington Royalty Research Fund Robert Wood Johnson Clinical Scholars Program