non-English Primary Language Research Articles

The association between primary language and quality of recovery following caesarean section: a prospective observational study

BackgroundNew Zealand has a diverse population, one quarter classifying themselves as migrants. This study aimed to test the hypothesis that women whose primary language is not English report poorer recovery scores following caesarean section than primary English speakers. MethodsWe recruited women to complete the ObsQoR-11 questionnaire 24 h after caesarean section. The questionnaire had been translated into the six most common languages spoken in our hospital. We categorised women into groups by primary language (English or non-English) and compared the ObsQoR-11 score between groups. ResultsFifty-nine surveys were analysed. Groups did not differ for urgency of surgery, anaesthetic technique or postoperative analgesia. Similar scores were achieved in domains assessing surgical and anaesthetic sequelae, whereas questions about function and ability to care for the baby were scored lower by those whose primary language was not English. The Obs-QoR-11 score was significantly higher in English primary language speakers compared with non-English primary language speakers (mean 81.2, SD 17.7 vs 64.1, SD 20.9, P=0.001; 95% CI of the difference 7.1 to 27.2). Subgroup analysis of the non-English primary language speakers (n=26) showed a mean (SD) of 68.6 (16.9) in those who were fluent in English and 64.1 (26.5) in those who were not (P=0.099, 95% CI of the difference −2.9 to 32.4). ConclusionQuality of recovery following caesarean section is poorer in those whose primary language is not English. Further research is needed to elucidate whether this is due to language barriers or other factors.

The Need for an Interpreter Increases Length of Stay and Influences Postoperative Disposition Following Primary Total Joint Arthroplasty

BackgroundMany US patients who undergo total joint arthroplasty have low English proficiency, yet no study has investigated how the need for a translator impacts postoperative outcomes for these patients. We hypothesized that need for an interpreter after total joint arthroplasty would impact discharge disposition and length of stay. MethodsWe performed a retrospective chart review of patients at a single large urban academic institution undergoing single primary total joint replacement from July 2016 to November 2019. Patients were classified as primarily English speaking (E), non-English primary language and did not require an interpreter (NE-N), or non-English primary language and did require an interpreter (NE-I). Data on patient characteristics, length of stay, and discharge disposition were collected. ResultsTotal hip arthroplasty (THA) patients in the NE-I group had significantly longer length of stay than both the NE-N group (2.85 vs 2.28 days, P = .015) and the E group (2.85 s vs 1.87 days, P < .0001). THA patients who required a translator were also significantly less likely to be discharged to home than those who were primarily English speaking (71.4% vs 88.8%, P < .0001). Total knee arthroplasty (TKA) patients in the NE-I group had significantly longer length of stay than the E group (2.66 vs 2.50 days, P = .009). The TKA patients in the NE-I group were significantly less likely to be discharged home than in the E group (74.5% vs 82.4%, P < .0001). ConclusionAlthough interpreter services are provided by the hospital for NE-I patients, the communication barrier that exists affects both length of stay and discharge disposition for both THA and TKA.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status

To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90days after discharge. This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors. Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits. Among immigrant mothers, non-English primary language, >5years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Retrospective analysis of the effect of limited english proficiency on abdominal MRI image quality.

To evaluate the effect of English proficiency on abdominal MRI imaging quality. Three equal-sized cohorts of patients undergoing 3T abdominal MRI were identified based on English proficiency as documented in the EMR: Primary language of English; English as a second language (ESL)/no translator needed; or ESL, translator needed (42 patients per cohort for total study size of 126 patients). Three radiologists independently used a 1-5 Likert scale to assess respiratory motion and image quality on turbo spin-echo T2WI and post-contrast T1WI. Groups were compared using Kruskal-Wallis tests. For T2WI respiratory motion, all three readers scored the Translator group significantly worse than the English and ESL/no-Translator groups (mean scores across readers of 2.98 vs. 3.58 and 3.51; p values < 0.001-0.008). For T2WI overall image quality, all three readers also scored the Translator group significantly worse than the English and ESL/no-Translator groups (2.77 vs. 3.28 and 3.31; p values 0.002-0.005). For T1WI respiratory motion, mean scores were not significantly different between groups (English: 4.14, ESL/no-Translator: 4.02, Translator: 3.94; p values 0.398-0.597). For T1WI overall image quality, mean scores also were not significantly different (4.09, 3.99, and 3.95, respectively; p values 0.369-0.831). Abdominal MR examinations show significantly worse T2WI respiratory motion and overall image quality when requiring a translator, even compared with non-translator exams in non-English primary language patients. Strategies are warranted to improve coordination among MR technologists, translators, and non-English speaking patients undergoing abdominal MR, to ensure robust image quality in this vulnerable patient population.

The Association of Primary Language With Emergency General Surgery Outcomes Using a Statewide Database

BackgroundEmergency general surgery (EGS) represents a diverse set of operations performed on acutely ill patients. Those undergoing EGS are at higher likelihood of complications, readmission, and death, but the effect of primary language on EGS outcomes has not been evaluated. We aimed to evaluate the association of non-English primary language on outcomes after EGS operations. MethodsThe New Jersey Statewide Inpatient Database from 2009 to 2014 was used to evaluate cases representing 80% of the national burden of EGS. Cases were restricted to ages ≥18 y, emergency department admissions, noted to be emergent or urgent, and performed between 0 and 2 d after admission. We evaluated Spanish speakers and non-English, non-Spanish (NENS) speakers compared with English. Outcomes included in-hospital mortality, 7-d readmission, and hospital length of stay (LOS). Logistic and negative binomial regression was used, and generalized linear mixed models were used to account for hierarchy in the data. ResultsThere were 105,171 patients included. English speakers were majority white and with private insurance; Spanish speakers were younger and with fewer comorbidities. Where differences between Spanish and NENS speakers existed, NENS were more like the English-speaking group. Adjusted results indicate that Spanish speakers had reduced LOS after appendectomy (IRR: 0.92 [0.89-0.95]) and lysis of adhesion [0.93 (0.88-0.97)]. Spanish speakers had an increased LOS after higher risk operations (IRR: 1.14 [1.10-1.20]). NENS speakers had a reduced LOS after adhesiolysis (IRR: 0.94 [0.89-0.99]). There was no difference in mortality or short-term readmission ConclusionsThese data from a large database suggest that the effect of primary language on LOS after EGS depends on the type of operation. Future studies should focus on long-term outcomes and determining if the lack of association we observed is generalizable to other regions of the United States.

Socioeconomic Risk Factors for Poor Outcomes of Developmental Dysplasia of the Hip

To examine the relationship between socioeconomic factors and outcomes of developmental dysplasia of the hip (DDH). A retrospective review of patients with DDH at a tertiary pediatric hospital from 2003 to 2012 with 2years minimum follow-up was conducted. The relationship between socioeconomic factors with late presentation, treatment, and outcomes was examined. Socioeconomic factors included insurance status, language, and ethnicity. In total, 188 patients met criteria. Patients with late presentations were more likely to be Hispanic (P=.02). However, public insurance and a non-English language were not associated with late presentation. Hispanic patients (P=.01) and patients with a non-English language (P=.01) had a lower nonoperative treatment success rate. Hispanic patients had more surgical procedures performed than non-Hispanic patients (P=.04). Patients with range of motion limitations were more likely to have public insurance (P=.05) and be Hispanic (P=.04). On multiple logistic regression analysis controlling for late presentation, patients with public insurance had increased odds of range of motion limitations (OR 2.22, P=.04). Patients with public insurance (OR 0.44, P=.04), a non-English primary language (OR 0.30, P<.01), and Hispanic ethnicity (OR 0.37, P=.01) had decreased odds of successful nonoperative treatment. Public insurance, a non-English language, and Hispanic ethnicity are risk factors for inferior outcomes for DDH. When controlling for late presentation, these were significant risk factors for nonoperative treatment failure.

Maternal Immigrant Status and Readiness to Transition to Home From the NICU.

Evaluate effects of immigrant status on perceptions of discharge readiness in mothers of preterm infants <37 weeks' gestation and identify the impact of primary language and years in the United States. Immigrant (n = 176) and native (n = 556) mothers of preterm infants cared for in the NICU for >5 days between 2012 and 2015 completed the Fragile Infant Parental Readiness Evaluation (FIPRE), a NICU-discharge readiness questionnaire. Group comparisons were made on the basis of immigrant status. Regression models examined effects of immigrant status, primary language, and years in the United States on discharge readiness. Immigrant mothers were more likely to be older, gravida >1, multiracial or people of color, and non-English speaking; have less than a high school education; and receive Medicaid but less likely to have child protective services involvement, substance abuse, and mental health disorder (MHD). Whereas rates of non-English primary language, low education, and Medicaid decreased, rates of MHDs increased with years in the United States. At NICU discharge, immigrant mothers had poorer perceptions of infant well-being, maternal well-being, maternal comfort, and time impact. In adjusted analyses, immigrant status, non-English primary language, and MHD predicted unfavorable scores. Among immigrant mothers, increased years in the United States and MHD predicted unfavorable scores. Although findings suggest acculturation with increased years in the United States, immigrant mothers perceived less discharge readiness in multiple domains, highlighting the need for culturally competent care and discharge services specifically tailored to help this vulnerable population.

Social determinants of psychological distress in Hpb cancer patients

Background: The diagnosis of hepatopancreaticobiliary (HPB) cancers can cause patients significant distress. Psychological distress has been shown to negatively impact cancer treatment, recovery, and ultimately, survival. Multiple factors may place patients at increased risk for psychological distress. Identification of factors placing patients at high risk for distress will enable care teams to pre-emptively intervene to improve the course of cancer care. Herein, we investigate the association of biopsychosocial factors with psychological distress of patients with HPB malignancies. Methods: A validated forty-eight item electronic distress screen was administered to new patients in the medical and surgical oncology clinics of a large cancer center from 2009 to 2015. Responses were recorded on a five-point Likert scale from 1, indicating no problem, to 5 indicating a very severe problem. Univariate and multivariate logistic regression analyses were performed to analyze factors that impacted the psychological distress status of patients. Results: A total of 1027 patients participated in biopsychosocial screening at a single institution from 2009-2015 of which 324 (31.5%) were HPB malignancies. The median age at screening was 65. Forty-eight percent of patients were female and 61% were Caucasian. Thirty-six percent of patients had at least a college degree. On univariate analysis, BMI ≥25 (OR 0.41, 95%CI 0.19–0.90, p = 0.03), male gender (OR 0.61, 95%CI 0.38–0.97, p = 0.03), and tobacco use (OR 5.17, 95%CI 1.35–19.70, p = 0.02) were significantly associated with an increased level of overall psychological distress. However, age, race, income, non-English primary language, and level of education were not associated with increased psychological distress. On multivariate analysis, BMI ≥25, gender and tobacco use all remained significantly associated with increased psychological distress, fearfulness and anxiety (p < 0.05). Conclusion: This study demonstrates that it is feasible to identify HPB cancer patients at high risk for psychological distress. HPB patients with a BMI ≥25, male gender, and tobacco users are more likely to experience this distress. Identifying these patients will allow for early intervention and potentially improved cancer recovery and survival.

Abstract WP332: Social Determinants of Access to Stroke Care in Women

Objective: To identify differences in access to stroke care in a multiethnic population of women. Methods: In this retrospective cohort study, all women hospitalized at an urban, public safety net hospital from January 1, 2012, through December 31, 2015, with possible stroke were ascertained. Male and transgender patients, as well as patients without an estimated time of stroke symptom onset, were excluded. Patient charts were reviewed by the study coauthors for demographics, pre-hospital characteristics, and details of acute care. Differences between groups were calculated using t-test, chi-square, one-way ANOVA or Kruskal-Wallis tests. Results: A total of 287 women were included in this study. The average age was 71±15 (range 28-100) years. Distribution of race/ethnicity was 36% Asian/Pacific Islander (n=103), 24% Hispanic (n=69), 21% Black (n=60), and 19% Caucasian (n=55). Forty-nine percent of patients spoke a primary language other than English: 22% Spanish, 17% Cantonese, and less than 3% Mandarin, Tagalog, Toisonese, Vietnamese, Russian, and other. Average latency between stroke symptom onset and hospital presentation was 10.9±21.3 hours; this did not differ by race/ethnicity [H(3)=2.683, p=0.443] or use of English as primary language (p=0.556). The number of patients who presented within 4.5 hours of symptom onset did not differ by race/ethnicity [χ 2 (3, n= 287) = 3.902, p=0.272] or use of English as primary language (p=0.5). However presentation to the emergency department by ambulance, as opposed to an alternate means of travel, trended toward significance when differentiated by race/ethnicity: 81% of Caucasians, 78% of Blacks, 68% of Asians/Pacific Islanders and 62% of Hispanics presented by ambulance [χ 2 (3, n= 287) = 7.723, p=0.052]. Ambulance use did not differ by use of English as the primary language [χ 2 (3, n=287) = 0.942, p=0.332). Administration of tPA, and door-to-needle time for tPA, were similar across races/ethnicities and primary language (p &gt; 0.1). Conclusions: While time to presentation and eligibility for stroke treatment did not differ by race/ethnicity or use of a non-English primary language, there may be a difference between races/ethnicities in the means of transport to the hospital for stroke care.

Sociodemographics and hypertension control among young adults with incident hypertension: a multidisciplinary group practice observational study.

Despite a growing prevalence of hypertension, young adults (18-39-year-olds) have lower hypertension control rates compared with older adults. The purpose of this study was to evaluate the role of sociodemographic factors in hypertension control among young adults with regular primary care access. A retrospective analysis included 3208 patients, 18-39 years old, who met clinical criteria for an initial (incident) hypertension diagnosis in a large, Midwestern, academic practice from 2008 to 2011. Patients with a prior antihypertensive medication prescription were excluded. Kaplan-Meier analysis was used to estimate the probability of achieving hypertension control over 24 months by sex. Cox proportional hazard models were fit to identify sociodemographic predictors of delays in hypertension control. Among the 3208 young adults with incident hypertension, 48% achieved hypertension control within 24 months. Kaplan-Meier analysis demonstrated that young women had a higher hypertension control rate at 24 months (57%) compared with young men (41%). According to adjusted hazard models, young men had a 39% lower rate of hypertension control (hazard ratio 0.61; 95% confidence interval 0.55-0.69) compared with women. Being unmarried (0.87; 0.78-0.98) and a non-English primary language speaker (0.47; 0.37-0.60) also predicted lower hypertension control rates. Sex disparities, being unmarried, and non-English primary language are important barriers to hypertension control among young adults with regular primary care use. Interventions tailored to sociodemographic characteristics may improve hypertension control in this challenging population.

Structural Vulnerability Associated with Radiation Treatment Gaps in Head and Neck Cancer Patients

Social determinants of health influence access to cancer screening, treatment and outcomes. Structural vulnerability (SV) is defined as an individual’s risk for negative health outcomes due to socioeconomic, cultural, and institutional factors as related to ability to access care and adhere to recommended treatment. In head and neck cancer (HNC) patients, missed radiation therapy (RT) leads to worse survival. We hypothesized that increased SV correlated with impaired RT adherence. This was a prospective IRB-approved survey offered to all HNC patients scheduled for at least 5 continuous weeks of RT. The survey assessed 8 domains of SV: financial security, food access, social support, legal status, physical security, access to shelter, functional health literacy, and perceived discrimination. Clinical data were extracted from the chart. Logistic regression analysis was used to identify factors associated with SV, adjusted for resources provided to patients (i.e. transport, housing, food). A total of 62 patients consented; 2 declined. The median age was 62 (range 53-83). 35% of patients identified as non-white, and 20% spoke a non-English primary language. Patients received RT for cancers of the oropharynx, oral cavity, larynx, nasopharynx, skin, salivary gland and thyroid. 23 (37%) reported financial insecurity and 9 (15%) reported discrimination. 3 (5%) did not have a place to sleep, 6 (10%) felt unsafe in their home/neighborhood, 5 (8%) did not have adequate food, 8 (13%) were without social support, 4 (6%) had legal concerns, and 12 (19%) had difficulty with medical documents. SV in any domain (p=0.006, OR 8.2, 95% CI 1.8-37.0) and the factor of financial insecurity (p=0.02, OR 5.2, CI 1.3-21.0) were significantly associated with ≥2 missed RT fractions. SV was associated with primary language other than English (p=0.007, OR 14.5, 95% CI 2.1-102). Patients with SV were 3.4 times more likely to miss fractions than those without SV, after adjusting for resources utilized (p=0.024, adjusted OR 3.4, 95% CI 1.2-9.9). This assessment reveals the multifaceted needs of our patients, beyond the purely financial, that threaten health outcomes. There are complex interplays of social hierarchy, power dynamics, and institutional policies that directly impact the health of our patients. Further study is needed to understand the impact of resources or services in mitigating these factors.

Socioeconomic Factors, Perioperative Complications, and 30-Day Readmission Rates Associated With Delayed Cranial Vault Reconstruction for Craniosynostosis.

Premature fusion of the cranial sutures can lead to significant neurocognitive, developmental, and esthetic consequences, especially if not corrected within the first year of life. This study aimed to identify the drivers of delayed cranial vault reconstruction (CVR) and its impact on complication and 30-day readmission rates among craniosynostosis patients. The medical records of all children who underwent CVR for craniosynostosis between 2005 and 2017 at an academic institution were retrospectively reviewed. A delay in operation was defined by surgery performed >12 months of age. Patient demographics, comorbidities, perioperative complication rates, and 30-day readmission rates were collected. A total of 96 patients underwent primary CVR, with 79 (82.3%) patients undergoing nondelayed surgery and 17 (17.7%) patients undergoing surgery >12 months of age. Children undergoing delayed surgery were significantly more likely to be non-White (P < 0.0001), have Medicaid insurance (P = 0.023), and have a non-English primary language (P < 0.005). There was increased incidence of developmental disability identified at first consult (no-delay: 3.9% vs delay: 41.2%, P < 0.0001) and increased intracranial pressure (no-delay: 6.3% vs delay: 29.4%, P < 0.005) among children undergoing delayed surgery. The delayed cohort had a significantly higher unplanned 30-day readmission rate (no-delay: 0.0% vs delay: 5.9%, P = 0.03). Our study suggests that craniosynostosis patients who are non-White, have a non-English primary language, and have Medicaid insurance are at risk for delayed primary surgery, which may lead to increased 30-day readmission. Interventions are necessary to reduce craniosynostosis patients' barriers to care to minimize the sequelae associated with delayed surgery.

In-Person Interpreter Use and Hospital Length of Stay among Infants with Low Birth Weight.

To ensure timely appropriate care for low-birth-weight (LBW) infants, healthcare providers must communicate effectively with parents, even when language barriers exist. We sought to evaluate whether non-English primary language (NEPL) and professional in-person interpreter use were associated with differential hospital length of stay for LBW infants, who may incur high healthcare costs. We analyzed data for 2047 infants born between 1 January 2008 and 30 April 2013 with weight <2500 g at one hospital with high NEPL prevalence. We evaluated relationships of NEPL and in-person interpreter use on length of stay, adjusting for medical severity. Overall, 396 (19%) had NEPL parents. Fifty-three percent of NEPL parents had documented interpreter use. Length of stay ranged from 1 to 195 days (median 11). Infants of NEPL parents with no interpreter use had a 49% shorter length of stay (adjusted incidence rate ratio (IRR) 0.51, 95% confidence interval (CI) 0.43–0.61) compared to English-speakers. Infants of parents with NEPL and low interpreter use (<25% of hospital days) had a 26% longer length of stay (adjusted IRR 1.26, 95% CI 1.06–1.51). NEPL and high interpreter use (>25% of hospital days) showed a trend for an even longer length of stay. Unmeasured clinical and social/cultural factors may contribute to differences in length of stay.

A Digital Language Divide? The Relationship between Internet Medication Refills and Medication Adherence among Limited English Proficient (LEP) Patients.

Use of an Internet portal to refill medicines positively affects medication adherence among English-speakers. No prior studies, however, have specifically examined the relationship between Internet refills and medicationadherence among patients who are limited English proficient (LEP). (1) Examine the relationship between Internet medication refill system use and medication adherence among linguistically diverse patients with chronic conditions and (2) compare this relationship between LEP and English-proficient (EP) patients. We analyzed 2013-2014 cross-sectional data from 509 surveyed adults in the Group Health Cooperative. Surveys were merged with plan enrollment, claims data, and electronic medical records. Medication adherence was calculated by the "Continuous Measure of Medication Gaps" (CMG) method. For Internet refill system use, patients were asked, "Have you used the health systems Internet site to refill any medications in the last 12 months?" LEP status was captured in the electronic medical record by a non-English primary language and a claims record of interpreter use in at least one clinical encounter between 2005 and 2012. We used multivariate linear regression models to examine Internet refill system use and medication adherence and compared the association between LEP and EP patients. Three hundred eighty-four patients (75%) had a calculable CMG: 134 EP and 250 LEP in the adherence analyses. In unadjusted analyses, LEP patients had lower use of the Internet refill system (p < .001) and lower adherence versus the EP group (p < .001). In multivariate analyses, LEP status (β = - 0.022, p = .047) was negatively associated with adherence, while use of the Internet refill system (β = 0.030, p = .002) was positively associated. In stratified models, use of Internet refills was positively associated with adherence, even when examining LEP (β = 0.029, p = .003) and EP patients (β = 0.027, p = .049) separately. These findings suggest that LEP patients may be under-utilizing a beneficial Internet tool. Should our healthcare systems fail to ensure that LEP patients have full and meaningful access to Internet patient portals, we risk worsening healthcare disparities.

Predictors and outcomes of delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography

Objective: Plastic biliary stents are commonly placed during endoscopic retrograde cholangiopancreatography (ERCP) and should be removed or replaced within 3 months to reduce the risk of stent obstruction. The aim of the study was to identify predictors and outcomes of patients who had delayed plastic biliary stent removal following ERCP.Materials and methods: Consecutive patients who received ERCP with plastic biliary stent placement at Loma Linda University Medical Center (10/2004–6/2013) were identified. Delayed removal was defined as presence of stent >3 months after index ERCP. Multivariable regression analysis to identify baseline characteristics associated with delayed removal was performed. Clinical outcomes of stent obstruction (e.g., cholangitis, hospitalization, intensive care) were also collected for those with delayed removal.Results: Among 374 patients undergoing ERCP with plastic biliary stent, 71 (19%) had delayed stent removal. Patients who had anesthesia assistance (AOR = 3.8, 95%CI 1.2–11.4), non-English primary language (AOR = 3.0, 95%CI 1.5–6.2), and outpatient ERCP (AOR = 2.0, 95%CI 1.1–3.4) had increased while choledocholithiasis (AOR = 0.5, 95%CI 0.3–0.99) had lower odds of delayed stent removal. Among those with delayed removal, 13 (18%) were hospitalized for stent obstruction (5 (7%) had cholangitis, 8 (11%) were hospitalized for more than a week, and 3 (4%) required intensive care).Conclusions: Almost one-fifth of patients who underwent ERCP with plastic biliary stent placement had delayed removal with nearly one-fifth of these patients requiring hospitalization for stent obstruction. Targeting patients at risk by improving communication and ease of scheduling an ERCP may reduce preventable adverse events associated with delayed biliary stent removal.

Family Language Barriers and Special-Needs Children.

* Abbreviations: CSHCN — : children with special health care needs ED — : emergency department LEP — : limited English proficiency NEPL — : non-English primary language RCT — : randomized controlled trial Approximately 63 million Americans speak a language other than English at home, and more than 26 million have limited English proficiency (LEP, defined as a self-reported ability to speak English less than very well).1,2 Approximately 12 million school-age children (22%) speak a language other than English at home, a number that has tripled since 1979.2 In the city of Houston, at least 145 languages are spoken at home.3 The marked growth in non–English primary language (NEPL) and LEP families is attributable to the rapid increase in America of the foreign-born population, which grew from 9.6 million in 1970 to 41.3 million in 2013.1,2 Numerous studies document that language barriers affect multiple aspects of health care, including access, health status, use of services, patient-physician communication, satisfaction with care, participation in clinical research, quality, and patient safety.1,2,4–7 The number of children with special health care needs (CSHCN) also has increased substantially. Approximately 16% of children in the United States (18 million) are CSHCN, and the number of CSHCN quadrupled between 1962 and 2005.8 CSHCN comprise almost two-thirds of pediatric hospitalizations, have longer mean hospital lengths of stay, and account for 90% of medical deaths among US children.8 These 2 demographic surges are colliding in America, as 13% of CSHCN reside in NEPL homes. Both populations are at high risk for adverse outcomes and compromised quality … Address correspondence to Ricardo A. Mosquera, MD, University of Texas Medical School at Houston, 6410 Fannin, Ste 510, Houston, TX. E-mail: ricardo.a.mosquera{at}uth.tmc.edu

Improvement in Adenoma Detection Rate in a High Risk Population Using Two Simple Interventions

Introduction: High quality colonoscopy is associated with favorable adenoma detection rates (ADR) and polyp detection rates (PDR), which improve outcomes related to colorectal cancer. Inadequate bowel preparation limits colonoscopy by impairing visualization, increasing cost, and decreasing PDR and ADR. Barriers to adequate bowel preparation include Medicaid health insurance, non-English primary language, lower educational background or health literacy, low patient motivation, and increased time to procedure. Using a Plan Do Study Act (PDSA) model, we implemented a split-dose bowel regimen and multi-lingual educational booklet, and achieved >90% prep adequacy. Here, we report the effect of improved bowel preparation on ADR in a diverse, high-risk population at a New York City public hospital. Methods: In 1/2014 we implemented a split-dose bowel preparation regimen (cycle 1). In 8/2014, we implemented a visual multi-language educational booklet in English, Spanish and Chinese (cycle 2). Individual patient data on polyps found and histopathology was collected during inception of the interventions from October 2013 to December 2014. Hospital data was collected for years 2013 and 2015, which included number of screening, colonoscopies and adenomas detected. Chi-square testing was performed in R (version 3.3.1) to evaluate the difference in ADR pre and post interventions. Results: There was an overall upward trend noted in PDR and ADR from October 2013 to December 2014 through each intervention cycle (Figure 1). Within this group, patients were similar in age (median = 57; p=0.56). Across the hospital, there were 1345 screening colonoscopies with 320 adenomas detected in 2013. Post intervention (2015) there was 1555 colonoscopies with 424 adenomas detected. An ADR of 24% was achieved in 2013 versus 27% in 2015 (p=0.0331).Figure 1Conclusion: Split-dose bowel preparation combined with a multi-language educational booklet to improve bowel preparation is associated with improved PDR and ADR in a high risk, ethnically diverse population. Utilizing the PDSA cycle we made a significant impact on two important quality markers, preparation adequacy and ADR.

Abstract WP246: Acute Ischemic Stroke Patients With a Primary Language Other Than English Do Not Have Significantly Increased Door-to-Needle Times for Intravenous TPA

Background: Rapid administration of intravenous alteplase (IV tPA) leads to better outcomes, but language barriers have the potential to introduce delays and to hinder effective communication with patients and collateral historians during the acute evaluation. Hypothesis: Acute ischemic stroke patients with a non-English primary language will have significantly longer door-to-needle times for IV tPA. Methods: We abstracted information on primary language for all adults that received IV tPA for acute ischemic stroke in the emergency department of an academic referral center in San Francisco, CA, from February 2008 to May 2015. Approximately 38% of San Francisco residents speak a language other than English at home. Primary language was determined from the electronic medical record and was confirmed by reviewing specific documentation in subsequent speech therapy evaluations and admission notes. Age, sex, race, presenting NIHSS, aphasia as a presenting symptom, whether the patient was accompanied to the emergency department by a family member or caregiver, discharge disposition, and door-to-needle (DTN) administration time for IV tPA were abstracted from clinical records and quality improvement registries. Results: A total of 237 patients received IV tPA for acute ischemic stroke in the emergency department during the study period. Median age was 76 years (IQR 64-86), 53% were female, and median DTN time was 62 minutes (IQR 48-86). A total of 34% of patients had a primary language other than English (20% Cantonese, 6% Russian, 3% Spanish). These patients were more likely to be older (median age 80 vs. 73 years, p = 0.001), to be accompanied by a family member or caregiver (80% vs. 59%, p = 0.003), and to have a higher NIHSS (median 9 vs. 11, p = 0.03), but DTN times were similar among English and non-English primary language speakers (median 62 vs. 62, p=0.88) and short-term outcomes were not significantly different (in-hospital mortality 9% English primary language vs 14% non-English primary language, p=0.27; discharge to home 43% vs 32%, p=0.16) . Conclusions: At a center serving a multiethnic population, a patient’s primary language did not appear to predict DTN times for acute ischemic stroke.

Abstract 9740: Factors Associated With Performing Urgent Coronary Angiography in Out-of-Hospital Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (OHCA) is associated with high mortality and is most commonly caused by cardiovascular disease. Current guidelines recommend urgent coronary angiography (UCA) if ST-elevation myocardial infarction (STEMI) or high suspicion of acute myocardial infarction exist. Some have advocated for UCA in all OHCA without an obvious non-cardiac cause of arrest. The reasons for large clinical variation in performance of UCA in OHCA are not well understood. Objective: We sought to identify factors associated with performing UCA in OHCA. Methods: A retrospective chart review was conducted on 535 consecutive cardiac arrest patients who achieved return of spontaneous circulation (ROSC) and were admitted at a tertiary academic medical center from January 2008 to August 2014. Exclusion criteria included in-hospital cardiac arrests (201), outside hospital UCA (8), and lack of medical records (1). Univariable analysis followed by multivariable forward selection forcing age and gender were used to determine correlates of performing UCA, defined as within 6 hours of presentation. Results: Out of 325 resuscitated OHCA patients (mean age, 64; women, 35%), 69 were taken to UCA. Factors associated with performing UCA were history of coronary artery disease (CAD) (OR 2.76, 95% CI 1.22-6.28), initial shockable rhythm (OR 3.04, 95% CI 1.31-7.06), following commands post-ROSC (OR 2.77, 95% CI 1.06-7.25), and STEMI (OR 15.17, 95% CI 6.57-35.04). Increasing age (OR 0.97, 95% CI 0.95-0.999) and obvious non-cardiac cause of arrest (OR 0.10, 95% CI 0.03-0.37) were negatively associated. Gender, prior stroke, dementia, bystander cardiopulmonary resuscitation, hypotension, contraindication to anticoagulant, presenting from nursing home or rehabilitation, do not resuscitate order prior to admission, non-English primary language, and presenting during off-hours were not associated with the decision for UCA. Conclusions: In resuscitated out-of-hospital cardiac arrest patients, history of CAD, shockable rhythm, ability to follow commands, and STEMI were associated with performing urgent coronary angiography. Older patients and those with an obvious non-cardiac cause of arrest were less likely to receive coronary angiography.

Health Literacy Rates in a Population of Patients with Rheumatoid Arthritis in Southwestern Ontario.

To determine the rate of low health literacy in the rheumatoid arthritis (RA) population in southwestern Ontario. For the study, 432 patients with RA were contacted, and 311 completed the assessment. The health literacy levels of the participants were estimated using 4 assessment tools administered in the following order: the Single Item Literacy Screener (SILS), the Medical Term Recognition Test (METER), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Shortened Test of Functional Health Literacy in Adults (STOFHLA). The rates of low literacy as estimated by STOFHLA, REALM, METER, and SILS were 14.5%, 14.8%, 14.1%, and 18.6%, respectively. All 4 assessment tools were statistically significantly correlated. STOFHLA, REALM, and METER were strongly correlated with each other (r = 0.59-0.79), while SILS only demonstrated moderate correlations with the other assessment tools (r = 0.33-0.45). Multiple linear regression and binary logistic regression analyses revealed that low levels of education and a lack of daily reading activity were common predictors of low health literacy. Using a non-English primary language at home was found to be a strong predictor of low health literacy in STOFHLA, REALM, and METER. Male sex was found to be a significant predictor of poor performance in REALM and METER, but not STOFHLA. Low health literacy is an important issue in the southwestern Ontario RA population. About 1 in 7 patients with RA may not have the necessary skills to become involved in making decisions regarding their personal health. Rheumatologists should be aware of the low health literacy levels of patients with RA and should consider identifying patients at risk of low health literacy.