Article

Language disparities in patients transported by emergency medical services

a b s t r a c t

Background: The population of the United States continues to diversify with an increasing percentage of residents with limited English proficiency (LEP). A major concern facing emergency medical services (EMS) providers is increasing scene and transport times. We hypothesized that there would be a significant difference in EMS scene and transport times when comparing LEP and English-speaking (ES) patients and there would be a difference in care, both in and out of hospital.

Methods: This is a retrospective case-control study with patient data extracted from hospital records and EMS run reports from a 911 emergency ambulance service. Patients were only included if they were transported to our level I trauma center. Inclusion in the LEP group was based on a field in EMS run reports that claimed language barrier as the sole reason for no patient signature. All LEP patients from July 1, 2012, to November 1, 2012, were reviewed. A random comparison sampling of ES patients from the same period was evaluated. The patients’ demographic data, pain scores, interventions, medications, transport times, and scene times were analyzed. Patients were followed up from emergency department (ED) management through to disposition. Percentages were compared using 95% confidence intervals (CIs). Bivariate analysis used the Student t test and ?2 test. A multivariable logistic regression model was created to determine predictive variables. A 5% random sampling was compared by 2 investigators for Interrater agreement.

Results: Data were collected from a total of 101 ES and 100 LEP patients. Interrater agreement was 94% between ex- tractors. Limited English proficiency patients were significantly older (56 +- 20 years old) than ES patients (41 +- 21 years old) and more likely to be female (odds ratio [OR], 2; 95% CI, 1.1-3.3). Limited English proficiency patients had a greater mean EMS transport time of 2.2 minutes (95% CI, 0.04-4.0). The odds of LEP patients receiving electrocar- diograms were greater both in the ambulance (OR, 3.7; 95% CI, 1.7-8.1) and in the ED (OR, 2.0; 95% CI, 1.1-3.3) compared to ES patients. There were no differences in additional interventions, medications administered, or pain scores obtained between the 2 groups. In a multivariable logistic regression model corrected for age, type of call, smoking history, and sex, there was no difference in transport times in LEP patients.

Conclusion: Compared to ES patients, LEP patients are older and more likely to be female. When corrected for differences in age, type of call, smoking history, and sex, we found no difference in scene or transport time for LEP patients. Results of this study indicate that EMS providers should be prepared for a different patient encounter when responding to 911 calls involving LEP patients rather than language variations alone.

(C) 2015

  1. Background

Two separate problems in ethnic disparity in health care are described in the literature: racial differences and language differences. Racial differences occur in patients regardless of their language [1-11]. Multiple studies have shown racial disparities in emergency depart- ment (ED) waiting time and length of stay (LOS) for a variety of admis- sion diagnoses. Analysis of the data shows that differences exist for problems such as acute stroke care [5,6], home health care [12,13], and length of ED stay [7,14].

? Presented at Society for Academic Emergency Medicine (SAEM) 2014 in Dallas, TX.

* Corresponding author.

E-mail address: [email protected] (N.R. Weiss).

The population of the United States continues to diversify with an in- creasing percentage of homes with limited English proficiency (LEP). Language disparity offers significantly more obstacles than racial dispar- ity, including lack of awareness of disease processes [15], inability to understand instructions and prescriptions [16], inability to use 911 services [17,18], and lack of providers who speak their language [3,19]. These problems also occur often in pediatrics and can be magni- fied in pediatric population [8,9,12,13,19-27].

Managing LEP patients can be challenging for emergency medical services (EMS) and in the EDs. Limited English proficiency patients in- creasingly use EMS [17,18,26] and EDs [7,10,11,14,21,23,28-30] as an entry point to health care. Multiple studies have shown that inter- preters, specifically Spanish interpreters, have many positive outcomes based on patient satisfaction and LOS in the ED [24,31-34]. Although in- terpreters are a growing force in most US hospitals, it is difficult to use

http://dx.doi.org/10.1016/j.ajem.2015.08.007

0735-6757/(C) 2015

Table 1

Baseline demographics comparing ES and LEP patients transported by EMS

ES

LEP

OR (95% CI)

Difference (95% CI)

201

101

100

Age

48 +- 21

41 +- 21

56 +- 20

15 (7.5-22.5)

Female sex

109 (54%)

46 (45%)

63 (63%)

2.0 (1.1-3.3)

Smoker

45 (22%)

30 (30%)

15 (15%)

0.3 (0.2-0.7)

Type of call

Medical

94 (47%)

52 (52%)

42 (42%)

NS

Trauma

88 (44%)

33 (33%)

55 (55%)

2.5 (1.4-5)

Pediatric

19 (10%)

16 (16%)

3 (3%)

0.2 (0.05-0.6)

Call priority

A

66 (33%)

30 (30%)

36 (36%)

NS

B

52 (26%)

30 (30%)

22 (22%)

NS

C

46 (23%)

20 (20%)

26 (26%)

NS

D

35 (17%)

20 (20%)

15 (15%)

NS

E

2 (1%)

1 (1%)

1 (1%)

NS

Time of day

Midnight-6 AM

37 (18%)

20 (20%)

17 (17%)

NS

6 AM-noon

51 (25%)

20 (20%)

31 (31%)

NS

Noon-6 PM

63 (31%)

35 (35%)

28 (28%)

NS

6 PM-midnight

50 (25%)

20 (26%)

24 (24%)

NS

Smoker

45 (22%)

30 (30%)

15 (15%)

0.3 (0.2-0.7)

ED time

595 +- 428

656 +- 453

534 +- 395

– 122 (4-240)

First EMS pain scores (N)

4.7 +- 4.0 (115)

4.7 +- 4.0 (63)

4.8 +- 4.1(52)

– NS

First ED pain scores(N)

4.7 +- 3.8 (161)

5.1 +- 3.8 (85)

4.2 +- 3.7 (76)

– NS

Odds ratios with 95% CIs are listed for discrete variables, and differences with 95% CIs are listed for continuous variables.

their services in the prehospital environment. No studies have exa- mined specifically whether EMS management of LEP patients differs in terms of field interventions, the duration of transport, or outcome. This study evaluated differences in EMS and ED care of LEP patients compared to English-speaking (ES) patients. Our primary hypothesis was that there would be a significant difference in EMS scene and transport times when comparing LEP and ES patients. In addition, we hypothesized that we would find a difference among LEP and ES patients in both EMS and ED care.

  1. Methods

In this retrospective case-control study, data on all patients transported by EMS were available in an agreement between

Albuquerque Ambulance Service and our ED for sharing research pur- poses. The study was approved by the university human research review committee and the institutional review board overseeing our local ambulance company.

The EMS system in our city handles approximately 50000 transports per year and has average transport times of 6 +- 4 minutes(range, 0-30 minutes). The distances to the main trauma center range within an 8- mile radius within the city limits. The hospital ED where patient care was evaluated is the main level 1 trauma center and is both a heart and a stroke center.

All LEP patients, as indicated by inability to sign the EMS run report secondary to language barrier, transported by the ambulance service between July 1, 2012, and November 1, 2012, were included. A random- ly chosen group of ES patients transported by the ambulance service

Table 2

Demographics comparing ES and LEP patients transported by EMS

ES

LEPs

OR (95% CI)

Difference (95% CI)

201

101

100

Scene time

18.5 +- 9.0

18.2 +- 9.3

18.8 +- 8.7

NS

Transport time

14.4 +- 6.4

13.3 +- 5.9

15.5 +- 6.7

2.2 (.04-4.0)

Change in EMS pain score (N)a

-0.7 +- 2.4 (87)

-0.7 +- 2.4 (39)

-0.6 +- 2.4 (48)

NS

Any interventions by EMS

123 (61%)

57 (57%)

65 (65%)

NS

ECG

39 (19%)

10 (10%)

29 (29%)

3.7 (1.7-8.1)

Any EMS meds

106 (53%)

51 (51%)

55 (55%)

NS

Pain meds

126 (63%)

59 (59%)

67 (67%)

NS

Antiemetics

9 (9%)

4 (4%)

5 (5%)

NS

ED time

595 +- 428

656 +- 453

534 +- 395

122 (4-240)

Change in ED pain score (N)a

-2.6 +- 3.4 (117)

-1.9 +- 2.9 (48)

-3.0 +- 3.6 (69)

NS

ED interventions

X-rays

130 (65%)

59(59%)

71 (71%)

NS

ECG

76 (38%)

30 (30%)

46 (46%)

2.0 (1.1-3.3)

Labs

151 (75%)

74 (74%)

77 (77%)

NS

ED meds

Pain meds

93 (46%)

44 (44%)

49 (49%)

NS

Antibiotics

21 (10%)

12 (12%)

9 (9%)

NS

Antiemetics

42 (21%)

17 (17%)

25 (25%)

NS

Disposition

Admit

64 (32%)

32 (32%)

32 (32%)

NS

Discharge

115 (57%)

53 (53%)

62 (62%)

NS

Other (LWBS and AMA)

20 (10%)

16 (15%)

4 (4%)

0.2 (0.1-0.7)

Odds ratios with 95% CIs are listed for discrete variables, and differences with 95% CIs are listed for continuous variables.

a Only included cases with both first and last pain scale while under care.

Table 3

Logistic regression for association of variables with language disparity (LEP)

Comparison

?

SE

Adjusted

95% CI

P

OR

Age

10-y difference

0.35

0.11

1.4

1.1-1.8

b.01

Sex

Female vs male

0.96

0.39

2.6

1.2-5.6

.01

Scene time

10-min difference

-0.4

0.21

0.7

0.4-1.02

.07

Transport time

Type of call

10-min difference

0.45

0.29

1.6

0.9-2.8

.12

Medical

Reference

Trauma

0.6

0.4

1.9

0.9-4.0

.09

Pediatrics

-0.7

0.9

0.5

0.1-2.8

.4

Smoking

Smoker vs nonsmoker

1.1

0.4

3.1

1.3-7.0

b.01

A priori variables entered into the model included age, sex, and scene and transport times. Type of call and smoking history were significant in bivariate analysis and were added into the model because they did not affect the goodness of fit (Hosmer-Lemeshow goodness- of-Fit test, 0.6).

between the same timeframe was considered for inclusion in the control group.

For these 2 study groups, study personnel accessed EMS transport run reports for information about the patients’ age, sex, acuity, and diagnosis. Emergency medical services scene and transport times, interventions, medications administered, and first and last EMS pain scale results were obtained. In addition, each patient was followed through the course of their ED stay. Data extracted on each patient included ED LOS, smoking history, first and last ED pain scale results, ED interventions, medications administered, and final disposition. The diagnosis of trauma was defined as any traumatic injury including Motor Vehicle Collision (MVCs), stab and gunshot wounds, burns, and fractures of any sort.

  1. Data analysis

Percentages were compared using 95% confidence intervals (CIs). Bi- variate analysis used the Student t test, Mann-Whitney U test, and ?2 test. A multivariable logistic regression model was created to determine predictive variables. Variables for the model were chosen a priori. A 5% random sampling was evaluated by 2 investigators for interrater agree- ment. Because EMS transport times were short, a 2-minute difference in transport times was considered a clinically relevant amount. This clini- cally significant difference was based solely on investigator opinion. As- suming an SD of 5 minutes on transport times in both groups, we had a power of 80% to show an absolute difference of 2 minutes in transport times with 100 patients in each group.

  1. Results

Data were collected from a total of 100 LEP patients during the 4-month study period. A total of 101 ES patients were chosen randomly from the same 4-month study period. Interrater agreement showed 94% agreement between extractors for EMS data and 72% agreement for ED data.

In bivariate analysis of baseline characteristics shown in Table 1, we noted that LEP patients were significantly older, with a mean difference of 15 years (95% CI, 7.5-22.5). Limited English proficiency patients were more likely to be female (odds ratio [OR], 2; 95% CI, 1.1-3.3) compared to ES patients. The etiology of 911 calls among LEP patients was more likely to be trauma related, with increased odds of 2.5 (95% CI, 1.4-5). Limited English proficiency patients were less likely to be pediatric (OR, 0.2; 95% CI, 0.05-0.6). The odds of smoking among LEP patients were 0.3 times less (95% CI, 0.2-0.7) than ES patients. We noted no sig- nificant differences in call priority, time of day, or initial pain scores. Table 2 lists details of EMS and ED management. There were longer transport times among LEP patients, with a mean difference of

2.2 minutes (95% CI, 0.04-4.0). The difference in scene times among both groups was not significant. We noted that LEP patients were

significantly more likely to have an electrocardiogram (ECG) done both in EMS care (OR, 3.7; 1.7-8.1) and in the ED (OR, 2.0; 1.1-1.3). Al- though EMS differences in ECGs could be a training issue, it was carried through to the ED as well. In addition, LEP patients were significantly less likely to leave without being seen (LWBS) or leave against medical advice (AMA) from the ED (OR, 0.2; 0.1-0.7).

We did a subgroup analysis of the 100 subjects based on ethnicity in the ES group. Of the 100 patients, 43 were Hispanic and 29 were white. We found that there were no significant differences in the transport times, odds of receiving an ECG, or odds of LWBS/AMA between these groups.

Table 3 shows the results of a multivariable logistic regression with age, sex, type of call, smoking history, and scene and transport times in- cluded in the model. Among LEP patients, the odds of having a 10-year age difference were 1.4 times greater (95% CI, 1.1-1.8; P b .01) than ES patients. The odds of LEP patients being female were 2.6 times greater (1.2-5.6; P = .01) than ES patients. Controlling for the age, type of call, smoking history, and sex in the model removed the significance of scene and transport time differences.

  1. Limitations

This case-control study is a retrospective review of hospital records and EMS run reports in 1 urban area. It has the limitations related to a retrospective review, where completion of variables cannot be ensured, as in the case of a prospective study. The patient demographics and EMS system model in our city may be different from other cities around the United States. In addition, we did not evaluate geographic data on the Patient transports and, therefore, cannot be certain that LEP patients were not concentrated in an area farther from the medical centers. A fu- ture study could evaluate exact locations for EMS scenes or zip codes from which the patients arose. We were able to obtain average time of calls and maximum distances to allow for understanding of the external validity of the results.

  1. Discussion

The results of our bivariate analyses indicate that LEP patients transported by EMS are older, more likely to be female, and less likely to smoke. These demographic differences may have influenced the rea- sons that the individuals call 911. We were unable to find any previous study in EMS or ED environment that had this great of a sex and age dif- ference between English speakers and LEPs. Language disparities affect whether sick patients call for prehospital help [17,18]. The area in which patients live, the previous experiences with EMS, and their understanding of the medical system may affect whether they make that call, suffer with their illness, or find another method of transport to the hospital.

We also noted a difference in the type of chief complaint for which patients were transported. Although we expected to see an increase in scene times and not transport times in our population, neither reached our acceptable level of significance in the multivariable analysis.

We did not find a difference in the number of patients who were

asked for their level of pain on a pain scale, the initial results in pain, or in the degree to which treatment alleviated their pain. Patients in both groups were more likely to get pain relief in the ED than in the prehospital arena. The EMS providers are both trained and equipped in the management of pain so it was surprising that they were unable to relieve patients’ pain. This is probably related to the much shorter time that patients are under EMS care. Lack of a difference in both EMS and ED pain scores is an important finding because many studies have found racial disparities in pain management. Numerous other studies have found racial disparities in pain reporting and management so we were surprised that we did not find this difference between our groups [11,35-37].

Electrocardiographic utilization is an interesting finding in this study. Both prehospital and ED ECGs were increased in LEP patients, whereas no other intervention was significantly different between the 2 groups. We can only explain this difference by the fact that with a lack of understanding of the patients’ complaint, the first and most pressing potential issue is cardiac; thus, ECGs are done to ensure that there is no acute cardiac disease.

It was anticipated that EMS differences between the 2 groups would correlate with changes in their ED management. Unlike previous stud- ies, we found a significantly longer ED LOS for LEP patients than for ES patients brought in by ambulance. This may be directly related to the types of illnesses and the particular patient biases about the appropriate use of the EMS system that makes LEP patients a different demographic group from the general ED population. A study by Wallbrecht et al [34] found no increased LOS for LEP patients unless they used an interpreter. Although Waxman et al [30] found no increase in LOS, they did find increased testing for patients with abdominal pain.

It was also surprising that LEP patients were very unlikely to LWBS or sign out AMA. It seems that once they reach medical care, they are more likely to follow through. Balakrishnan et al [38] found that there was a high degree of misclassification of LEP patients as ES at triage, which led to a high degree of dissatisfaction among these patients. Spanish-speaking patients have also been noted to have fewer physician visits than ES patients [39]. Perhaps by the time LEP patients reach the ED, they have exhausted all options for care and need to stay for the entire length of time.

An important question to us was the distinction between language disparity and Racial disparity. When we looked at the racial disparity among the ES patients, the significant findings of this study disappeared. This suggests that the issue affecting patient care is not a racial disparity but rather a true language disparity leading to significant obstacles to care. Language barriers have been shown to increase the risk of adverse outcomes in hospitalized patients [40,41]. Language barriers were asso- ciated with decreased knowledge of heart attacks and strokes [15] and decreased immunizations [3]. Patients with language barriers have an increased ED LOS [23] and are at a higher risk for ED returns for admission [22].

  1. Conclusion

Compared to ES patients, LEP patients were older on average and had greater odds of being female. When corrected for differences in age, type of call, smoking history, and sex in a logistic regression model, we found no significant differences in EMS transport or scene times, for LEP patients. We found no difference in the percentage of patients who received any EMS or ED medications. However, LEP patients tended to receive more ECGs overall. Understanding the differences between LEP and ES patients will help to reduce disparities and improve care on the part of EMS and ED providers.

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