1. The Effect of Professional Medical Interpretation in the Pediatric ED Louis Hampers, MD, MBA Medical Director, Emergency Department Associate Professor of Pediatrics University of Colorado School of Medicine

2. The Problem 2000 Census –For 18% of US residents, English is not primary language –8% limited English proficient (LEP)

3. The Problem Patient/Provider language barriers negatively impact: –access –efficiency –satisfaction –quality errors adherence baseline health

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

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

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

7. Interpreter Effect North side of Chicago University pediatric ED ~40,000 visits/yr ~50% Latino ~10% LEP Archives of Pediatrics and Adolescent Medicine 2002;156:1108

8. Setting Winter 1997-1998 –“on-call” interpreters –42% coverage Winter 1999-2000 –full-time interpreters (2.5 FTE’s) –91% coverage

9. Professional Interpreters No certification in State of IL 40 hrs training 4 hrs “shadowing” Wage/benefits ~ $17/hr “Family Support Services” Payors not billed

10. Design Prospective Inclusion: T > 38.5 o C 2 mo to 10 yrs + or vomiting or diarrhea Clinical appearance recorded

11. Design Prospective Cohorts Does this patient’s family speak English? Did this present a language barrier for you? Did you use an interpreter?

12. Cohorts

13. English speaking InterpreterBilingual MD No interpreter AdmissionIVF bolus Test costLength of stay % % $min

14. Non-English Speaking Patients (Versus English Speakers) *P<.05

15. 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

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

17. Will telephonic interpretation help mitigate the premium?

18. Prospective Study Downtown Denver University pediatric ED ~45,000 visits/yr ~50% Latino ~10% LEP

19. Randomized Design Families asked at triage language of preference for medical interview Even calendar days: “in-person” days Odd calendar days: “telephone” days (CyraCom) Pt’s got a bilingual provider if one was available, regardless of calendar day –“bilingual” providers verified

20. Outcome Measures Families surveyed 3-7 days after visit –investigator blinded to interpretation mode How do you rate: –your physician? –the interpretation? –overall satisfaction with the visit? Did you wish discharge instructions had been explained more clearly? What did they tell you was wrong with your child?

21. LEP families N=203 Bilingual provider available? Yes No? Randomize Bilingual provider N=42 In-person N=93 Telephonic N=68 Blinded, post-visit survey

23. Conclusions All 3 approaches seem to work well 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

24. Research Issue Challenges: –What outcomes should we look at? –defining and measuring costs costs of providing interpreters more evident than costs of not providing them –costs to whom?