Limited English Proficient Patient Visits and Emergency Department Admission Rates for Ambulatory Care Sensitive Conditions in California: a Retrospective Cohort Study

Journal of General Internal Medicine (2021)Cite this article

Abstract

Background

Little is known about the risk of admission for emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) by limited English proficient (LEP) patients.

Objective

Estimate admission rates from ED for ACSCs comparing LEP and English proficient (EP) patients and examine how these rates vary at hospitals with a high versus low proportion of LEP patients.

Design

Retrospective cohort study of California’s 2017 inpatient and ED administrative data

Participants

Community-dwelling individuals ≥ 18 years without a primary diagnosis of pregnancy or childbirth. LEP patients had a principal language other than English.

Main Measures

We used a series of linear probability models with incremental sets of covariates, including patient demographics, primary diagnosis, and Elixhauser comorbidities, to examine admission rate for visits of LEP versus EP patients. We then added an interaction covariate for high versus low LEP-serving hospital. We estimated models with and without hospital-level random effects.

Key Results

These analyses included 9,641,689 ED visits; 14.7% were for LEP patients. . Observed rate of admission for all ACSC ED visits was higher for LEP than for EP patients (26.2% vs. 25.2; p value < .001). Adjusted rate of admission was not statistically significant (27.3% [95% CI 25.4–29.3%] vs. 26.2% [95% CI 24.3–28.1%]). For COPD, the difference was significant (36.8% [95% CI 35.0–38.6%] vs. 33.3% [95% CI 31.7–34.9%]). Difference in adjusted admission rate for LEP versus EP visits did not differ in high versus low LEP-serving hospitals.

Conclusions

In adjusted analyses, LEP was not a risk factor for admission for most ACSCs. This finding was observed in both high and low LEP-serving hospitals.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

US$ 39.95

Tax calculation will be finalised during checkout.

Figure 1
Figure 2

References

  1. 1.

    Lu T, Myerson R. Disparities in Health Insurance Coverage and Access to Care by English Language Proficiency in the USA, 2006–2016. J Gen Intern Med. 2020. https://doi.org/10.1007/s11606-019-05609-z

  2. 2.

    DuBard CA, Gizlice Z. Language spoken and differences in health status, access to care, and receipt of preventive services among US Hispanics. Am J Public Health 2008;98(11):2021-2028. https://doi.org/10.2105/AJPH.2007.119008

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Garcia ME, Bindman AB, Coffman J. Language-Concordant Primary Care Physicians for a Diverse Population: The View from California. Health Equity 2019;3(1):343-349. https://doi.org/10.1089/heq.2019.0035

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Diamond LC, Tuot DS, Karliner LS. The Use of Spanish Language Skills by Physicians and Nurses: Policy Implications for Teaching and Testing. J Gen Intern Med 2012;27(1):117-123. https://doi.org/10.1007/s11606-011-1779-5

    Article  PubMed  Google Scholar 

  5. 5.

    Schenker Y, Pérez-Stable EJ, Nickleach D, Karliner LS. Patterns of interpreter use for hospitalized patients with limited English proficiency. J Gen Intern Med 2011;26(7):712-717. https://doi.org/10.1007/s11606-010-1619-z

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Calo WA, Cubillos L, Breen J, et al. Experiences of Latinos with limited English proficiency with patient registration systems and their interactions with clinic front office staff: an exploratory study to inform community-based translational research in North Carolina. BMC Health Serv Res. 2015;15(1). 10.1186/s12913-015-1235-z

  7. 7.

    Regan Freeman R. Primary care for limited English-speaking patients and parents. J Am Assoc Nurse Pract 2015;27(3):167-176. https://doi.org/10.1002/2327-6924.12148

    Article  Google Scholar 

  8. 8.

    Morales LS, Cunningham WE, Brown JA, Liu H, Hays RD. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med 1999;14(7):409-417.

    CAS  Article  Google Scholar 

  9. 9.

    Pippins JR, Alegría M, Haas JS. Association between language proficiency and the quality of primary care among a national sample of insured Latinos. Med Care 2007;45(11):1020-1025. https://doi.org/10.1097/MLR.0b013e31814847be

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Njeru JW, St Sauver JL, Jacobson DJ, et al. Emergency department and inpatient health care utilization among patients who require interpreter services. BMC Health Serv Res 2015;15:214. https://doi.org/10.1186/s12913-015-0874-4

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Schulson L, Novack V, Smulowitz PB, Dechen T, Landon BE. Emergency Department Care for Patients with Limited English Proficiency: a Retrospective Cohort Study. J Gen Intern Med Published online September 5, 2018. https://doi.org/10.1007/s11606-018-4493-8

  12. 12.

    Gallagher RA, Porter S, Monuteaux MC, Stack AM. Unscheduled return visits to the emergency department: the impact of language. Pediatr Emerg Care 2013;29(5):579-583. https://doi.org/10.1097/PEC.0b013e31828e62f4

    Article  PubMed  Google Scholar 

  13. 13.

    Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language barriers and resource utilization in a pediatric emergency department. Pediatrics. 1999;103(6 Pt 1):1253-1256.

    CAS  Article  Google Scholar 

  14. 14.

    Anderson TS, Karliner LS, Lin GA. Association of Primary Language and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care 2020;58(1):45-51. https://doi.org/10.1097/MLR.0000000000001245

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Agency for Healthcare Research and Quality. Prevention quality indicators overview. 2018. https://www.qualityindicators.ahrq.gov/modules/pqi_resources.aspx

  16. 16.

    Zong J, Batalova J. The Limited English Proficient Population in the United States. Migr Policy Inst Published online July 8, 2015. https://www.migrationpolicy.org/article/limited-english-proficient-population-united-states

  17. 17.

    American Community Survey. California Department of Finance Estimates and Projections; US Census Bureau Estimates; Decennial Censuses.; 2017.

  18. 18.

    California Emergency Department & Ambulatory Surgery Data Reporting Manual. 5th ed. Office of Statewide Health Planning and Development; 2020. https://oshpd.ca.gov/data-and-reports/submit-data/patient-data/edas-reporting/

  19. 19.

    Inpatient Discharge Reporting. Office of Statewide Health Planning and Development; 2020. https://oshpd.ca.gov/data-and-reports/submit-data/patient-data/inpatient-reporting/

  20. 20.

    Biswas S, Dinh D, Lucas M, et al. Impact of limited English proficiency on presentation and clinical outcomes of patients undergoing primary percutaneous coronary intervention. Eur Heart J - Qual Care Clin Outcomes. Published online November 29, 2019:qcz061. 10.1093/ehjqcco/qcz061

  21. 21.

    Hines A, Andrews R, Moy E, Barrett M, Coffey R. Disparities in Rates of Inpatient Mortality and Adverse Events: Race/Ethnicity and Language as Independent Contributors. Int J Environ Res Public Health 2014;11(12):13017-13034. https://doi.org/10.3390/ijerph111213017

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    American Community Survery 2012-2016. United States Census Bureau

  23. 23.

    Centers for Disease Control and Prevention. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Published online 2017. Accessed March 5, 2018. http://www.cdc.gov/nchs/icd/icd9cm. htm.

  24. 24.

    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998;36(1):8-27. https://doi.org/10.1097/00005650-199801000-00004

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Colin Cameron A, Miller DL. A Practitioner’s Guide to Cluster-Robust Inference. J Hum Resour 2015;50(2):317-372. https://doi.org/10.3368/jhr.50.2.317

    Article  Google Scholar 

  26. 26.

    Health Care Interpreter Network. Healthcare Interpreter Network: About Us. . http://www.hcin.org/

  27. 27.

    Escutia, Perata. The Health Care Language Access Act (SB 853).; 2003.

  28. 28.

    Access and Cost Trends, Medical Expenditure Panel Survey, 2017. Agency for Healthcare Research and Quality; 2017.

  29. 29.

    Wisnivesky JP, Krauskopf K, Wolf MS, et al. The association between language proficiency and outcomes of elderly patients with asthma. Ann Allergy Asthma Immunol Off Publ Am Coll Allergy Asthma Immunol 2012;109(3):179-184. https://doi.org/10.1016/j.anai.2012.06.016

    Article  Google Scholar 

  30. 30.

    Kim EJ, Kim T, Paasche-Orlow MK, Rose AJ, Hanchate AD. Disparities in Hypertension Associated with Limited English Proficiency. J Gen Intern Med 2017;32(6):632-639. https://doi.org/10.1007/s11606-017-3999-9

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Seman M, Karanatsios B, Simons K, et al. The impact of cultural and linguistic diversity on hospital readmission in patients hospitalized with acute heart failure. Eur Heart J - Qual Care Clin Outcomes. Published online July 23, 2019:qcz034. https://doi.org/10.1093/ehjqcco/qcz034

  32. 32.

    Mayo R, Parker VG, Sherrill WW, et al. Cutting Corners: Provider Perceptions of Interpretation Services and Factors Related to Use of an Ad Hoc Interpreter. Hisp Health Care Int 2016;14(2):73-80. https://doi.org/10.1177/1540415316646097

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Hsieh E. Not just “getting by”: factors influencing providers’ choice of interpreters. J Gen Intern Med 2015;30(1):75-82. https://doi.org/10.1007/s11606-014-3066-8

    Article  PubMed  Google Scholar 

  34. 34.

    Ramirez D, Engel KG, Tang TS. Language interpreter utilization in the emergency department setting: a clinical review. J Health Care Poor Underserved 2008;19(2):352-362. https://doi.org/10.1353/hpu.0.0019

    Article  PubMed  Google Scholar 

  35. 35.

    Fernandez A, Schillinger D, Warton EM, et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med 2011;26(2):170-176. https://doi.org/10.1007/s11606-010-1507-6

    Article  PubMed  Google Scholar 

  36. 36.

    Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med 2007;22 Suppl 2:324-330. https://doi.org/10.1007/s11606-007-0340-z

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Villalobos BT, Bridges AJ, Anastasia EA, Ojeda CA, Rodriguez JH, Gomez D. Effects of language concordance and interpreter use on therapeutic alliance in Spanish-speaking integrated behavioral health care patients. Psychol Serv 2016;13(1):49-59. https://doi.org/10.1037/ser0000051

    Article  PubMed  Google Scholar 

  38. 38.

    Green AR, Ngo-Metzger Q, Legedza ATR, Massagli MP, Phillips RS, Iezzoni LI. Interpreter services, language concordance, and health care quality. Experiences of Asian Americans with limited English proficiency. J Gen Intern Med 2005;20(11):1050-1056. https://doi.org/10.1111/j.1525-1497.2005.0223.x

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Diamond L, Izquierdo K, Canfield D, Matsoukas K, Gany F. A Systematic Review of the Impact of Patient-Physician Non-English Language Concordance on Quality of Care and Outcomes. J Gen Intern Med 2019;34(8):1591-1606. https://doi.org/10.1007/s11606-019-04847-5

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Yeheskel A, Rawal S. Exploring the “Patient Experience” of Individuals with Limited English Proficiency: A Scoping Review. J Immigr Minor Health 2019;21(4):853-878. https://doi.org/10.1007/s10903-018-0816-4

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Shaw SJ, Huebner C, Armin J, Orzech K, Orzech K, Vivian J. The role of culture in health literacy and chronic disease screening and management. J Immigr Minor Health 2009;11(6):460-467. https://doi.org/10.1007/s10903-008-9135-5

    Article  Google Scholar 

  42. 42.

    Klinger EV, Carlini SV, Gonzalez I, et al. Accuracy of race, ethnicity, and language preference in an electronic health record. J Gen Intern Med 2015;30(6):719-723. https://doi.org/10.1007/s11606-014-3102-8

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to acknowledge Lisa Marks for her technical support.

Funding

This work was supported in part by a Health Resources and Services Administration’s National Research Service Award (T32HP10028) (Dr. Schulson), Agency for Healthcare Research and Quality Award (T32HS022242) (Dr. Lin), and National Institute on Minority Health and Health Disparities Grant R01MD011594 (Dr. Hanchate).

Author information

Affiliations

  1. Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA

    Lucy Schulson MD, MPH & Michael K. Paasche-Orlow MD, MA, MPH

  2. RAND Corporation, 20 Park Plaza #920, Boston, MA, 02116, USA

    Lucy Schulson MD, MPH

  3. Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA

    Meng-Yun Lin PhD, MPH & Amresh D. Hanchate PhD

Authors
  1. Lucy Schulson MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Meng-Yun Lin PhD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael K. Paasche-Orlow MD, MA, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Amresh D. Hanchate PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lucy Schulson MD, MPH.

Ethics declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

ESM 1

(DOCX 34 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Schulson, L., Lin, MY., Paasche-Orlow, M.K. et al. Limited English Proficient Patient Visits and Emergency Department Admission Rates for Ambulatory Care Sensitive Conditions in California: a Retrospective Cohort Study. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-020-06523-5

Download citation

KEY WORDS

  • limited English proficiency
  • health disparities
  • ambulatory care sensitive conditions