Bridging Language Gaps May Boost Outcomes

Marcia Frellick

October 22, 2019

Patients with low English proficiency (LEP) discharged with chronic  conditions may be at considerably higher risk for revisiting and reentering the hospital and may need additional attention, research published online today in JAMA indicates.

That risk is not surprising to Danielle Ofri, MD, PhD, an internist at Bellevue Hospital in New York City. The most "miraculous treatment" means nothing if patients can't understand what they are to do when they go home, she told Medscape Medical News.

"The doctor/patient or the nurse/patient conversation is the single-most powerful tool in medicine. Bar none," she continued.

That's why one of the first questions she asks her patients is, "How many years of school did you complete?"

She asks it nonchalantly, in between questions about smoking and drinking and family members so it seems like just another item on the checklist.

But the answer may reveal much more.

"It is quite common for me to come across answers of sixth grade, third grade," said Ofri, who sees patients at the oldest public hospital in the United States.

Emphasizing the Most Crucial Information

If the patient struggles with English, extra communication efforts may be needed.

One method, Ofri said, is deciding which two bits of information are the most essential and finding a way to emphasize that information, either with repetition or even drawing a diagram.

Nurse callbacks days after discharge can also help determine whether the patient has encountered problems in filling prescriptions and making follow-up appointments. Separate nurse visits when patients can bring in every bottle of medicine for reconciliation also helps, Ofri said, though that becomes a resource issue.

Another strategy is asking the patient to repeat back to the clinician or to a translator what they understand, she said, adding that hearing and understanding are very different things.

It also helps to reframe questions about medications to say, "Everyone has challenges in taking medications. What are the challenges you've had?" to take away the stigma, Ofri said.

Even translators may not be able to relay the nuances of words that could help treatment.

Ofri said a French translator once told her that when providers use what they see as the simpler word for diuretics – "water pills" – Haitian patients see that translation as a placebo, so why bother.

"One can only imagine how many things like this there are," Ofri continued.

Physicians should also be aware that pride may keep a patient from answering honestly, she noted.

She began to ask about level of education years ago after she was convinced her efforts to sort and organize a detailed medication instruction list for a patient in his 70s would fix his noncompliance.

She was frustrated that the patient, born in a small village in Central America, seemed to have no idea how to take an array of medicines.

She reintroduced the list on several occasions. After 2 years, he finally let her know he could not read. He had never gone to school.

There's another reason she asks about level of education.

"One of the best medical interventions is to help patients get a GED," she said, adding that if she knows they haven't completed high school, she can point them toward that step.

Much Higher Risk of Returning to Hospital

In the current study, Shail Rawal, MD, MPH, with the Department of Medicine at the University of Toronto in Canada, and colleagues looked at all patients discharged with one of four conditions — pneumonia, hip fracture,  exacerbations of chronic obstructive pulmonary disease (COPD) or heart failure — from two academic hospitals in Toronto between 2008 and the first quarter of 2016.

Patients with LEP and heart failure had a 32% higher relative risk (RR) of a 30-day emergency department (ED) visit (RR 1.32; 95% confidence interval [CI], 1.12 - 1.55) compared with patients who were English proficient.

Patients with LEP and heart failure had a 29% greater risk of readmission at 30 days (RR, 1.29; 95% CI, 1.08 - 1.54) and 24% at 90 days (RR, 1.24; 95% CI, 1.09 -1.40).

Patients with LEP and COPD also had a 51% greater risk of readmission at 30 days (RR, 1.51; 95% CI, 1.11 - 2.06) and a 32% increased risk at 90 days (RR, 1.32; 95% CI, 1.06 - 1.65), but did not have significantly increased risk of a 30-day ED visit (RR, 1.25; 95% CI, 0.95-1.66) than did patients who were English proficient.

There was no significant difference in returns or readmissions to the ED between the two groups among patients discharged with hip fracture or pneumonia.

That may have something to do with the nature of the treatments that are prescribed for those two conditions, Rawal and colleagues suggest.

The authors make a distinction in the article between conditions that may be more sensitive to good communication and need more support, such as COPD and heart failure, and those that may be less communication-sensitive, including pneumonia and hip fracture, because they have fairly simple, well-established, short-term treatment regimens.

Ofri agreed they should have different considerations.

"Pneumonia is a finite episode," she said. And physical therapy is straight-forward for hip fracture.

"But CHF [congestive heart failure] and COPD — those are lifelong and it's all about education. They are much more complex, cognitive issues," she explained.

Discharge information cannot be done in 10 minutes, she added.

"If you want to do a good hospital discharge you need to have enough nurses so a nurse can sit with the patient for 30 minutes. And have a nurse call the patient or visit the patient in 2 days," she said.

"But that's staffing, that's money," she acknowledged.

JAMA. Published online October 22, 2019. Full text

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