The Effect of Professional Medical Interpretation in the Pediatric ED

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 20035e569
5
Excuses?

• Ad hoc interpreters good enough
• Professional interpreters slow things down
• Patients didnt ask for/dont want interpreters
• ?HIPAA
• Provider with good enough language skills
• Insurance wont 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 20031116
7
Interpreter Effect

• North side of Chicago
• University pediatric ED
• 40,000 visits/yr
• 50 Latino
• 10 LEP

Archives of Pediatrics and Adolescent Medicine
20021561108
8
Setting

• Winter 1997-1998
• on-call interpreters
• 42 coverage
• Winter 1999-2000
• full-time interpreters (2.5 FTEs)
• 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
DesignProspective

• Inclusion
• T gt 38.5oC
• 2 mo to 10 yrs or
• vomiting or diarrhea
• Clinical appearance recorded

11
DesignProspective Cohorts

• Does this patients family speak English?
• Did this present a language barrier for you?
• Did you use an interpreter?

12
Cohorts
13
Admission
IVF bolus


Test cost
Length of stay

min
English speaking
No interpreter
Interpreter
Bilingual MD
14
Non-English Speaking Patients(Versus English
Speakers)
Plt.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 didnt 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)
• Pts 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 N203
Bilingual provider available?
Yes
No? Randomize
In-person N93
Telephonic N68
Bilingual provider N42
Blinded, post-visit survey
22
(No Transcript)
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?