Patients with limited English proficiency (LEP) experience lower quality end-of-life (EOL) care. This inequity may have been exacerbated during the COVID-19 pandemic.
Objective:
Compare health care utilization, EOL, and palliative care outcomes between COVID-19 decedents with and without LEP during the pandemic's first wave in Massachusetts.
Methods:
Retrospective cohort study of adult inpatients who died from COVID-19 between February 18, 2020 and May 18, 2020 at two academic and four community hospitals within a greater Boston health care system. We performed multivariable regression adjusting for patient sociodemographic variables and hospital characteristics. Primary outcome was place of death (intensive care unit [ICU] vs. non-ICU). Secondary outcomes included hospital and ICU length of stay and time to initial palliative care consultation.
Results:
Among 337 patients, 89 (26.4%) had LEP and 248 (73.6%) were English proficient. Patients with LEP were less often white (24 [27.0%] vs. 193 [77.8%]; p < 0.001); were more often Hispanic or Latinx (40 [45.0%] vs. 13 [5.2%]; p < 0.001); and less often had a medical order for life-sustaining treatment (MOLST) on admission (15 [16.9%] vs. 120 [48.4%]; p < 0.001) versus patients with English proficiency. In the multivariable analyses, LEP was not independently associated with ICU death, ICU length of stay, or time to palliative care consultation, but was independently associated with increased hospital length of stay (mean difference 4.12 days; 95% CI, 1.72–6.53; p < 0.001).
Conclusions:
Inpatient COVID-19 decedents with LEP were not at increased risk of an ICU death, but were associated with an increased hospital length of stay versus inpatient COVID-19 decedents with English proficiency.
Get full access to this article
View all access options for this article.
References
1.
MooreJT, RicaldiJN, RoseCE, et al.: Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5–18, 2020–2022 States, February-June 2020. MMWR Morb Mortal Wkly Rep, 2020; 69:1122–1126.
2.
WadheraRK, WadheraP, GabaP, et al.: Variation in COVID-19 hospitalizations and deaths across New York City boroughs. JAMA, 2020; 323:2192–2195.
3.
FigueroaJF, WadheraRK, LeeD, et al.: Community-level factors associated with racial and ethnic disparities in COVID-19 rates in Massachusetts. Health Aff (Millwood), 2020; 39:1984–1992.
4.
MartinezDA, HinsonJS, KleinEY, et al.: SARS-CoV-2 positivity rate for Latinos in the Baltimore-Washington, DC region. JAMA, 2020; 324:392–395.
Rodriguez-DiazCE, Guilamo-RamosV, MenaL, et al.: Risk for COVID-19 infection and death among Latinos in the United States: Examining heterogeneity in transmission dynamics. Ann Epidemiol, 2020; 52:46–53 e42.
7.
KarmakarM, LantzPM, TipirneniR: Association of social and demographic factors with COVID-19 incidence and death rates in the US. JAMA Netw Open, 2021; 4:e2036462.
8.
BarwiseA, JaramilloC, NovotnyP, et al.: Differences in code status and end-of-life decision making in patients with limited English proficiency in the intensive care unit. Mayo Clin Proc, 2018; 93:1271–1281.
9.
SilvaMD, GenoffM, ZaballaA, et al.: Interpreting at the end of life: A systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency. J Pain Symptom Manage, 2016; 51:569–580.
10.
ThorntonJD, PhamK, EngelbergRA, et al.: Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences. Crit Care Med, 2009; 37:89–95.
11.
PhamK, ThorntonJD, EngelbergRA, et al.: Alterations during medical interpretation of ICU family conferences that interfere with or enhance communication. Chest, 2008; 134:109–116.
12.
SchiaffinoMK, NaraA, MaoL: Language services in hospitals vary by ownership and location. Health Aff (Millwood), 2016; 35:1399–1403.
13.
SchenkerY, FernandezA, KerrK, et al.: Interpretation for discussions about end-of-life issues: Results from a National Survey of Health Care Interpreters. J Palliat Med, 2012; 15:1019–1026.
ShenMJ, MaciejewskiPK, TergasAI, et al.: Inequities in end-of-life care among immigrant patients exaggerated by the COVID-19 pandemic. J Pain Symptom Manage, 2021; 62:e3–e4.
ChuziS, MolsberryR, McCabeME, et al.: Distribution in place of death for COVID-19-related mortality in the United States. J Am Geriatr Soc, 2020; 68:1917–1918.
19.
ChuaIS, ShiSM, and LevineDM: Place of death and end-of-life care utilization among COVID-19 decedents in a Massachusetts health care system. J Palliat Med, 2021; 24:322–323.
20.
NgaiKM, GrudzenCR, LeeR, et al.: The association between limited English Proficiency and Unplanned Emergency Department revisit within 72 hours. Ann Emerg Med, 2016; 68:213–221.
21.
QureshiMM, RomesserPB, JalisiS, et al.: The influence of limited English proficiency on outcome in patients treated with radiotherapy for head and neck cancer. Patient Educ Couns, 2014; 97:276–282.
22.
ParkerMM, FernándezA, MoffetHH, et al.: Association of patient-physician language concordance and glycemic control for limited-English proficiency Latinos with type 2 diabetes. JAMA Intern Med, 2017; 177:380–387.
23.
EarleCC, ParkER, LaiB, et al.: Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol, 2003; 21:1133–1138.
24.
GrunfeldE, UrquhartR, MykhalovskiyE, et al.: Toward population-based indicators of quality end-of-life care: Testing stakeholder agreement. Cancer, 2008; 112:2301–2308.
25.
LindvallC, LilleyEJ, ZupancSN, et al.: Natural language processing to assess end-of-life quality indicators in cancer patients receiving palliative surgery. J Palliat Med, 2019; 22:183–187.
26.
BernackiR, HutchingsM, VickJ, et al.: Development of the serious illness care program: A randomised controlled trial of a palliative care communication intervention. BMJ Open, 2015; 5:e009032.
27.
PaladinoJ, BernackiR, NevilleBA, et al.: Evaluating an intervention to improve communication between oncology clinicians and patients with life-limiting cancer: A cluster randomized clinical trial of the Serious Illness Care Program. JAMA Oncol, 2019; 5:801–809.
28.
LakinJR, KoritsanszkyLA, CunninghamR, et al.: A systematic intervention to improve serious illness communication in primary care. Health Affairs, 2017; 36:1258–1264.
29.
LeverJ, KrzywinskiM, and AltmanN: Points of significance: Model selection and overfitting. Nat Methods, 2016; 13:703–704.
30.
Weech-MaldonadoR, MoralesLS, ElliottM, et al.: Race/ethnicity, language, and patients' assessments of care in Medicaid managed care. Health Serv Res, 2003; 38:789–808.
31.
SeidM, StevensGD, and VarniJW: Parents' perceptions of pediatric primary care quality: Effects of race/ethnicity, language, and access. Health Serv Res, 2003; 38:1009–1031.
32.
NguyenD and ReardonLJ: The role of race and English proficiency on the health of older immigrants. Soc Work Health Care, 2013; 52:599–617.
33.
Grace YiEH: Does acculturation matter? End-of-life care planning and preference of foreign-born older immigrants in the United States. Innov Aging, 2019; 3:igz012.
34.
MatsumuraS, BitoS, LiuH, et al.: Acculturation of attitudes toward end-of-life care: A cross-cultural survey of Japanese Americans and Japanese. J Gen Intern Med, 2002; 17:531–539.
35.
WrightAA, StieglitzH, KupersztochYM, et al.: United states acculturation and cancer patients' end-of-life care. PLoS One, 2013; 8:e58663.
36.
YarnellCJ, FuL, ManuelD, et al.: Association between immigrant status and end-of-life care in Ontario, Canada. JAMA, 2017; 318:1479–1488.
37.
DeSanto-MadeyaS, NilssonM, LoggersET, et al.: Associations between United States acculturation and the end-of-life experience of caregivers of patients with advanced cancer. J Palliat Med, 2009; 12:1143–1149.
38.
LeeS, NguyenHA, and TsuiJ: Interview language: A proxy measure for acculturation among Asian Americans in a population-based survey. J Immigr Minor Health, 2011; 13:244–252.
39.
KangS-M: Measurement of acculturation, scale formats, and language competence: Their implications for adjustment. J Crosscult Psychol, 2006; 37:669—693.
JacksonVA, SullivanAM, GadmerNM, et al.: “It was haunting…”: Physicians' descriptions of emotionally powerful patient deaths. Acad Med, 2005; 80:648–656.
42.
SteinhauserKE, ChristakisNA, ClippEC, et al.: Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA, 2000; 284:2476–2482.
43.
LeiterRE: Reentry. N Engl J Med, 2020; 383:e141.
44.
CookDJ, TakaokaA, HoadN, et al.: Clinician perspectives on caring for dying patients during the pandemic: A mixed-methods study. Ann Intern Med, 2021; 174:493–500.
45.
FramptonS, AgrawalS, and GuastelloS: Guidelines for family presence policies during the COVID-19 pandemic. JAMA Health Forum, 2020; 1:e200807.
46.
Ngo-MetzgerQ, SorkinDH, PhillipsRS, et al.: Providing high-quality care for limited English proficient patients: The importance of language concordance and interpreter use. J Gen Intern Med, 2007; 22Suppl 2(Suppl 2):324–330.
47.
John-BaptisteA, NaglieG, TomlinsonG, et al.: The effect of English language proficiency on length of stay and in-hospital mortality. J Gen Intern Med, 2004; 19:221–228.
48.
LindholmM, HargravesJL, FergusonWJ, et al.: Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med, 2012; 27:1294–1299.
49.
NorrisWM, WenrichMD, NielsenEL, et al.: Communication about end-of-life care between language-discordant patients and clinicians: Insights from medical interpreters. J Palliat Med 2005;8:1016–1024.
50.
ButowPN, LobbE, JeffordM, et al.: A bridge between cultures: Interpreters' perspectives of consultations with migrant oncology patients. Support Care Cancer, 2012; 20:235–244.
51.
SilvaMD, TsaiS, SobotaRM, et al.: Missed opportunities when communicating with limited English-proficient patients during end-of-life conversations: Insights from Spanish-speaking and Chinese-speaking medical interpreters. J Pain Symptom Manage, 2020; 59:694–701.
KenisonTC, MaduA, KrupatE, et al.: Through the veil of language: Exploring the hidden curriculum for the care of patients with limited English proficiency. Acad Med, 2017; 92:92–100.
54.
Foiles SifuentesAM, Robledo CornejoM, LiNC, et al.: The role of limited English proficiency and access to health insurance and health care in the affordable care act era. Health Equity, 2020; 4:509–517.
55.
ButkusR, RappK, CooneyTG, et al.: Envisioning a better U.S. health care system for all: Reducing barriers to care and addressing social determinants of health. Ann Intern Med, 2020; 172:S50–s59.
56.
KnueselS, ChuangW, OlsonE, et al.: Language barriers, equity, and COVID-19: The impact of a novel Spanish language care group. J Hosp Med, 2021; 16:109–111.
HerzbergEM, Barrero-CastilleroA, and MatuteJD: The healing power of language: Caring for patients with limited English proficiency and COVID-19. Pediatr Res, 2022; 91:526–528.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
