Strategies Used by Prehospital Providers to Overcome Language Barriers.

OBJECTIVE: Language barriers are commonly encountered in the prehospital setting but there is a paucity of research on how prehospital providers address language discordance. We sought to identify the communication strategies, and the limitations of those strategies, used by emergency medical services (EMS) providers when confronted with language barriers in a variety of linguistic and cultural contexts. METHODS: EMS providers were queried regarding communication strategies to overcome language barriers as part of an international, multi-site, sequential explanatory, qualitative-predominant, mixed methods study of prehospital language barriers. A survey of EMS telecommunicators was administered at dispatch centers in New Mexico (United States) and Western Cape (South Africa). Semi-structured qualitative interviews of EMS field providers were conducted at agencies who respond to calls from participating dispatch centers. Survey data included quantitative data on demographics and communication strategies used to overcome language barriers as well as qualitative free-text responses on the limitations of strategies. Interviews elicited narratives of encounters with language-discordant patients and the strategies used to communicate. Data from the surveys and interviews were integrated at the point of analysis. RESULTS: 125 telecommunicators (overall response rate of 84.5%) and a purposive sample of 27 field providers participated in the study. The characteristics of participants varied between countries and between agencies, consistent with variations in participating agencies' hiring and training practices. Telecommunicators identified 3rd-party telephonic interpreter services as the single most effective strategy when available, but also described time delays and frustration with interpreter communications that leads them to preferentially try other strategies. In the field, all providers reported using similar strategies, relying heavily on bystanders, multilingual coworkers, and non-verbal communication. Prehospital providers described significant limitations to these strategies, including time delays, breaches of patient confidentiality, and inaccurate interpretation. Participants suggested various resources to improve communication with language-discordant patients. CONCLUSIONS: Prehospital providers rely upon similar, informal strategies for overcoming language barriers across a variety of locations, provider types, and linguistic and cultural contexts.

The Need for More Prehospital Research on Language Barriers: A Narrative Review.

INTRODUCTION: Despite evidence from other healthcare settings that language barriers negatively impact patient outcomes, the literature on language barriers in emergency medical services (EMS) has not been previously summarized. The objective of this study is to systematically review existing studies of the impact of language barriers on prehospital emergency care and identify opportunities for future research. METHODS: A systematic review with narrative synthesis of publications with populations specific to the prehospital setting and outcome measures specific to language barriers was conducted. A four-prong search strategy of academic databases (PubMed, Academic Search Complete, and Clinical Key) through March 2015, web-based search for gray literature, search of citation lists, and review of key conference proceedings using pre-defined eligibility criteria was used. Language-related outcomes were categorized and reported as community-specific outcomes, EMS provider-specific outcomes, patient-specific outcomes, or health system-specific outcomes. RESULTS: Twenty-two studies met eligibility criteria for review. Ten publications (45%) focused on community-specific outcomes. Language barriers are perceived as a barrier by minority language speaking communities to activating EMS. Eleven publications (50%) reported outcomes specific to EMS providers, with six of these studies focused on EMS dispatch. EMS dispatchers describe less accurate and delayed dispatch of resources when confronted with language discordant callers, as well as limitations in the ability to provide medical direction to callers. There is a paucity of research on EMS treatment and transport decisions, and no studies provided patient-specific or health system-specific outcomes. Key research gaps include identifying the mechanisms by which language barriers impact care, the effect of language barriers on EMS utilization and clinically significant outcomes, and the cost implications of addressing language barriers. CONCLUSION: The existing research on prehospital language barriers is largely exploratory, and substantial gaps in understanding the interaction between language barriers and prehospital care have yet to be addressed. Future research should be focused on clarifying the clinical and cost implications of prehospital language barriers.

Triage in the Tower of Babel: interpreter services for children in the prehospital setting.

Minority pediatric populations have higher rates of emergency medical services use than the general pediatric population, and prior studies have documented that limited-English proficiency patients are more likely to undergo invasive procedures, require more resources, and be admitted once they arrive in the emergency department. Furthermore, limited-English proficiency patients may be particularly vulnerable because of immigration or political concerns. In this case report, we describe an infant with breath-holding spells for whom a language barrier in the prehospital setting resulted in an escalation of care to the highest level of trauma team activation. This infant underwent unnecessary, costly, and harmful interventions because of a lack of interpreter services. In a discussion of the legal, ethical, and medical implications of this case, we conclude that further investigation into prehospital strategies for overcoming language barriers is required to provide optimal prehospital care for pediatric patients.

Primary care physicians who treat blacks and whites.

BACKGROUND: In the United States, black patients generally receive lower-quality health care than white patients. Black patients may receive their care from a subgroup of physicians whose qualifications or resources are inferior to those of the physicians who treat white patients. METHODS: We performed a cross-sectional analysis of 150,391 visits by black Medicare beneficiaries and white Medicare beneficiaries 65 years of age or older for medical "evaluation and management" who were seen by 4355 primary care physicians who participated in a biannual telephone survey, the 2000-2001 Community Tracking Study Physician Survey. RESULTS: Most visits by black patients were with a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent, P=0.02) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs. 19.3 percent, P=0.005). The physicians treating black patients also reported facing greater difficulties in obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital. CONCLUSIONS: Black patients and white patients are to a large extent treated by different physicians. The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients. Further research should be conducted to address the extent to which these differences may be responsible for disparities in health care.

Variations in lung cancer risk among smokers.

BACKGROUND: Although there is no proven benefit associated with screening for lung cancer, screening programs are attracting many individuals who perceive themselves to be at high risk due to smoking. We sought to determine whether the risk of lung cancer varies predictably among smokers. METHODS: We used data on 18 172 subjects enrolled in the Carotene and Retinol Efficacy Trial (CARET)-a large, randomized trial of lung cancer prevention-to derive a lung cancer risk prediction model. Model inputs included the subject's age, sex, asbestos exposure history, and smoking history. We assessed the model's calibration by comparing predicted and observed rates of lung cancer across risk deciles and validated it by assessing the extent to which a model estimated on data from five CARET study sites could predict events in the sixth study site. We then applied the model to evaluate the risk of lung cancer among smokers enrolled in a study of lung cancer screening with computed tomography (CT). RESULTS: The model was internally valid and well calibrated. Ten-year lung cancer risk varied greatly among participants in the CT study, from 15% for a 68-year-old man who has smoked two packs per day for 50 years and continues to smoke, to 0.8% for a 51-year-old woman who smoked one pack per day for 28 years before quitting 9 years earlier. Even among the subset of CT study participants who would be eligible for a clinical trial of cancer prevention, risk varied greatly. CONCLUSIONS: The risk of lung cancer varies widely among smokers. Accurate risk prediction may help individuals who are contemplating voluntary screening to balance the potential benefits and risks. Risk prediction may also be useful for researchers designing clinical trials of lung cancer prevention.

Screening for lung cancer: a review of the current literature.

STUDY OBJECTIVES: To review the available data on the early detection of lung cancer, with a focus on three technologies: chest x-ray (CXR), sputum cytology, and low-dose CT (LDCT) scanning. DESIGN, SETTING, PARTICIPANTS: Review of published clinical studies of early detection technologies. The best available evidence on each topic was selected for analysis. Randomized trials were used to evaluate CXR and sputum cytology. Cohort studies, as well as studies providing evidence regarding rates of overdiagnosis and efficacy of initial treatment, were considered in evaluation of LDCT. Study design and results were summarized in evidence tables. Statistical analyses of combined data were not performed. MEASUREMENT AND RESULTS: Five randomized trials of CXR with or without sputum cytology have been conducted, each which reports disease-specific mortality as well as other end points. None of these studies provide support for the use of either CXR or sputum cytology for the early detection of lung cancer in asymptomatic individuals. Eight completed and ongoing trials of LDCT were identified. All of these studies report the frequency and stage distribution of lung cancers found during initial ("prevalence") screening, and several studies also report rates of detection at the time of annual follow-up. No outcome data on survival or treatment are available. A number of studies support the hypothesis of "overdiagnosis"--that some lung cancers detected by LDCT may behave in an indolent manner. CONCLUSIONS: The use of either CXR or sputum cytology for the early detection of lung cancer is not supported by the published evidence. The evidence for LDCT appears promising, in that the technology typically identifies lung cancer at an early stage, although corollary studies suggest that these findings in isolation may be misleading. Further high-quality research is needed to better define the role of LDCT in the evaluation of asymptomatic high-risk individuals.