1. Medical Interpreting: Outcomes, Errors, and Understanding The Center for Immigrant Health New York University School of Medicine

2. Thanks! UHF Altman New York Community Trust Commonwealth Fund California Endowment

3. The Center for Immigrant Health NYU School of Medicine Founded in 1989 Network of community members/CBOs/FBOs, providers, researchers, facilities and administrators, program and policymakers Mission: To facilitate the delivery of linguistically, culturally, and epidemiologically sensitive healthcare services to newcomer populations to reduce health disparities Research, Education, Program/Policy Dvpt

4. PARTNERS

5. Linguistic Diversity: United States 1990 Census 31 million spoke a language other than English 14 million considered limited English proficient 2000 Census 47 million speak a language other than English 21 million considered limited English proficient

6. % LEP Change by State Source: Access Project & National Health Law Program

7. Filipino21% Indian27% Italian36.1% Pakistani48% Spanish50% Russian64.5% Chinese70% Proportion of NYC Immigrant Population that is LEP Source: New York City Department of Planning

8. Study Series: A Series of Firsts Randomized study: impact of MI modes upon medical outcomes and costs Comparative study of accuracy Determination of efficiencies across modalities

9. Intervention:Remote Simultaneous Medical Interpreting System(RSMI) Trained Simultaneous Medical Interpreters Remotely Located, Pooled Resource Spanish, Mandarin, Cantonese, Bengla

10. Research Questions Does RSMI Improve Timely Diagnosis of Depression? Does RSMI Facilitate Appropriate Follow-up Care?

11. Research Questions Does RSMI Improve Adherence to Screening Guidelines? Does RSMI Improve Outcomes for Chronic Diseases? Diabetes, Hypertension, and Hypercholesterolemia

12. Research Questions Does RSMI lead to fewer interpreting errors? Is RSMI a more efficient form of interpreting? Does RSMI lead to improved understanding of exit instructions

13. Cost Analysis Research Questions: Pending Are visit lengths different across different modalities? Are there fewer repeat visits to achieve the same outcomes? Are there differences in test ordering behaviors, hence, costs? What are the opportunity costs vis-a-vis staff time? Hospitalizations/ER visits prevented

14. Error Analysis and Efficiency Scripted Encounters: Spanish and Chinese: TB, Menopause, Diabetes, Depression Bengali: Breast Cancer RSMI, Proximate Consecutive, Over-the- telephone Consecutive, Ad Hoc Patient/Doctor Actors Encounters Audiotaped and Transcribed

15. Error Analysis Tool Word-by-word, and by concept Linguistic errors: meaningful and non- meaningful Medical errors: no, mild, moderate, high, and life-threatening significance HPI, meds/allergies, family history, diagnosis, plan, psychosocial, F/U, patient education

16. Error Analysis Panel Linguist and 3 physicians, at least 2 bilingual Scored separately, then discussed differences until consensus

17. Error Analysis  Error rate per utterance  Medically significant/Category  Time  Control for training

18. Spanish Error Analysis RSMI versus non-RSMI RSMI 30% as likely to result in potential medical error **p<0.05

19. Spanish Error Analysis: Odds Ratio of a moderately significant to life-threatening error Trained Proximate Consecutive Trained Remote Consecutive Ad Hoc(18 yrs experience) Trained Remote Simultaneous 6.3*** 7.54*** 1.71 1.00 ***p<0.001

20. Error Analysis Efficiency Results MeanNMethod 1420.754Distal Consecutive 1174.754Proximal Consecutive 1095.004Proximal Ad-Hoc 762.004RSMI Mean time (in seconds) for each group

21. Spanish Efficiency RSMI is 30% faster than the next fastest mode(ad hoc) RSMI two times faster than over-the- phone consecutive  Spanish encounters more accurate and efficient with RSMI

22. Different Languages May be Different Mandarin Analyses in Progress

23. Bengali Error Analysis Standardized Training Standardized Practice One Script Across All Modes

24. Results/Bengali:Training

25. Training Matters 27% of errors made by untrained interpreters were of moderate or greater clinical significance vs. 8.5% of errors made by trained interpreters Vocabulary precision rate.69 for trained vs. 0.34 for the untrained

26. Training: Error Examples Dr: The results were positive which means that you carry the gene that puts you at risk for developing breast cancer Int: The results were correct Dr: One important thing that you have going for you is the fact that the cancer has probably been caught early Int: One important thing is the fact that the cancer is working quickly in your body Dr: The doxy could hurt your heart Int: The doxy can give you pain

27. Study Design: Outcomes Randomized Control for Discordant(Spanish- English, Mandarin-English, Cantonese- English) RSMI Usual and Customary Language Concordant Encounters: English- English, Spanish-Spanish, Chinese-Chinese

28. Data Collection:Depression, Medical Outcomes,Knowledge Clinic  Intake Questionnaire, including Beck Depression Index  Chart Reviews and Computerized Tracking for 1 Year after Enrollment  Exit Interviews  Several Hundred Enrolled ER  Intake Questionnaire  Audiotaped Visits  Exit Interviews  Patient Understanding Scale

29. Clinic Population 782 patients enrolled RSMI and U&C comparable in demographics including age, gender, education, years in U.S., primary language, English proficiency, acculturation, and self-reported health status

30. Randomization Assignment and Exposure Group

31. Spanish-speaking Clinic Study Patients, n=465 n=282 n= Country of Origin Years in the U.S Gender Age

32. Chinese-speaking Study Patients, n=208. Years in the U.S Gender Age

33. Spanish-speaking ER Patients, n=225 Length of Stay in U.S. Country of Origin Age Gender

34. Immigrants at Risk: Language and Influenza Vaccination 462 patients were enrolled in the study between November 2003 and July 2004 102 were at the highest risk of complications from influenza (chronic medical condition, age, or pregnancy) Only 10 patients in this group were referred for vaccination 9 received vaccination 54 patients aged 50 to 64 years without underlying medical conditions composed a second group who were eligible 4 in this group were referred for and received flu vaccination None of the Cantonese or Mandarin-speaking patients in either group received vaccination.

35. CLEAN: RSMI associated with a higher referral rate for screening colonoscopy (OR of 1.7) compared with U&C Physicians in “language concordant” encounters had lower rates of referrals for screening colonoscopy than language discordant

36. Instructions Given Audiotape analyses of 214 ER Spanish language encounters Spanish language concordant, RSMI, U&C Trained RSMI mean # instructions per encounter: 14.29,std dv 6.9 equal to Spanish language concordant (14.33, std dev 6.33) Usual and customary interpreting significantly fewer instructions: mean # 11.9, std dev 6.17

37. Diabetes Management Research question: Does RSMI lead to improved management of diabetes mellitus? 74 patients with DM Young patient population at clinic Guidelines for DM management as per the American Diabetes Association (ADA)

38. Methodology Score computed based on ADA guidelines considering following: A1C 1st visitPodiatry referral A1C 3 months laterEye doc referral BP recordedNutrition referral LDL orderedFlu shot referral Weight recordedPneumovax referral Urine spot or 24h ordered Smoking cessation referral (if eligible) Prescribed aspirin (if eligible)

39. Results RSMIU&CLCP value Randomized Score Mean0.310.280.303 gps 0.80 SD0.180.140.172 gps 0.50 Exposure Score Mean0.380.220.303 gps 0.02 SD0.190.120.152 gps 0.01

40. Diagnosis of Depression Research question: Does RSMI Improve Timely Diagnosis of Depression? Why depression? Common disorder in the primary care setting Associated with significant morbidity Effective communication is key in diagnosis

41. Methodology Beck’s Depression Inventory Validated in Spanish and Chinese Screening tool Administered to patients at intake by research assistant BDI score of 4 or more considered as positive RSMI, U&C, LC compared in terms of rate of diagnosis by physicians and matched against the expected rate from the BDI score

42. Results BDI +ve rates BDI +ve 153 BDI -ve 309 BDI not done 320 intake process, BDI at end of interview Demographics comparable in BDI +ve, -ve, and not done Significant trends observed: Diagnosis rate best in LC, followed by RSMI and then U&C Time to medication in new diagnosis of depression better in RSMI compared with U&C

43. Randomization * Comparing all 3 groups: Chi-square P=0.66, Fisher P=0.65 ** Comparing RSMI vs U&C: Chi-square P=0.41, Fisher P=0.47 Exposure * Comparing all 3 groups: Chi-square P=0.83, Fisher P=0.85 ** Comparing RSMI vs U&C: Chi-square P=0.58, Fisher P=0.76 Randomization * Comparing all 3 groups: Chi-square P=0.66, Fisher P=0.65 ** Comparing RSMI vs U&C: Chi-square P=0.41, Fisher P=0.47 Exposure * Comparing all 3 groups: Chi-square P=0.83, Fisher P=0.85 ** Comparing RSMI vs U&C: Chi-square P=0.58, Fisher P=0.76

44. Patient Satisfaction/Understanding Perception ER and Clinic Combined First Visits Language Concordant(E-E,Sp-Sp, M-M, Ca-Ca), RSMI, Usual and Customary

45. Understanding MD Understands Pt Underst Explan Pt Under Instructions LCRS MI UCLCRS MI UCLCRS MI UC VW 69%49%35%59%39%34%63%38%32% W 33%49%55%33%52%50%33%54%59% NW 2% 10%4%9%15%3%8%9%

46. Satisfaction How would you rate the MD overall? LC RSMI UC Ex 63% 56% 49% Gd 32% 40% 44% Fa 4% 4% 4% How satisfied with care overall? LC RSMI UC Very 57% 57% 47% Swht 38% 40% 48% SwtDis 4% 3% 5%

47. How well did the method protect your privacy? RSMI U&C Very Well 49% 40% Well 44% 49% Not Well 7% 10% Poor 0% 1%

48. No Difference How well did the interpreter understand you? Did the interpreter listen carefully(yes/no)? Did the interpreter treat you with respect?(trend) How well did the interpreter interpret?(trend)

49. Implications for Policy Training matters….training programs should be systematized. Investment in dissemination of RSMI to users of telephone interpreting services will provide cost savings even without consideration of seemingly improved outcomes(?). For Spanish-language encounters, RSMI will likely provide the most accurate results, and better patient outcomes. First ever randomized trial of impact of varying modes of interpreting. Results can provide basis for institutional and federal/state/local policy evidence-based decision-making.