The Third National Conference on
Quality Health Care for Culturally Diverse Populations:
Advancing Effective Health Care through Systems Development, Data, and Measurement

October 2 - 4, 2002, Chicago, IL
Westin Chicago River North Hotel

Session C-1: Making the case for quality interpreter services: research update

Lost in Translation: Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters

Background
About 19 million people in the US are limited in English proficiency, but little is known about the frequency and potential clinical consequences of errors in medical interpretation.

Objectives
To determine the frequency, categories, and potential clinical consequences of errors in medical interpretation.

Methods
During a 7-month period, we audiotaped and transcribed pediatric encounters in a hospital outpatient clinic in which a Spanish interpreter was used. For each transcript, we categorized each error in medical interpretation, and determined whether errors had a potential clinical consequence.

Results
Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs. 53%; P <.0001). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of solely to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media.

Conclusions
Errors in medical interpretation are common, Averaging 31 per clinical encounter, and omissions are the most frequent type. Most errors have potential clinical consequences, and those committed by ad hoc interpreters are significantly more likely to have potential clinical consequences than those committed by hospital interpreters. Because errors by ad hoc interpreters are more likely to have potential clinical consequences, third-party reimbursement for trained interpreter services should be considered for patients with limited English proficiency.

Dr. Flores is Associate Professor of Pediatrics, Epidemiology and Health Policy at the Medical College of Wisconsin, where he is also Director of Community Outcomes and Associate Director of the Center for the Advancement of Urban Children in the Department of Pediatrics. He is a Robert Wood Johnson Generalist Physician Faculty Scholar and a former Robert Wood Johnson Minority Medical Faculty Scholar. He has published 40 articles and book chapters on a variety of topics, including "Culture and the patient-physician relationship: achieving cultural competency in health care" (Journal of Pediatrics 2000;136:14-23), and "The health of Latino children: Urgent priorities, unanswered questions, and a research agenda" (Journal of the American Medical Association 2002;288:82-90).

Dr. Flores presents an annual workshop on cultural competency at the Pediatric Academic Societies’ Meetings. He is co-founder and co-director of the Special Interest Group on Culture, Ethnicity, and Health Care of the Ambulatory Pediatric Association. He also chairs the Latino Consortium of the American Academy of Pediatrics Center for Child Health Research. Dr. Flores is a member of the Health Care Research Training Study Section of the Agency for Healthcare Research and Quality (AHRQ). Dr. Flores’s current research includes an investigation of interpreter errors and their clinical consequences (funded by the Office of Minority Health), and studies on insuring uninsured children (funded by the Agency for Healthcare Research and Quality, the Center for Medicare and Medicaid Studies, and the Robert Wood Johnson Foundation).

Glenn Flores, MD
Associate Professor of Pediatrics, Epidemiology & Health Policy
Director, Community Outcomes
Associate Director, Center for the Advancement of Urban Children
Department of Pediatrics
Medical College of Wisconsin
8701 Watertown Plank Road
Milwaukee, WI 53226
Phone: 414-456-4454
Fax: 414-456-6539
E-mail: gflores@mail.mcw.edu

Effects of Interpreter Services on Limited English Proficient Patients' Healthcare Use

Sharon M. Lee and Guadalupe Pacheco

This study examines the effects of professional interpreter services on health visit levels and patterns of a sample of limited English proficient (LEP) members of a large managed care organization (MCO) in the Portland, Oregon metropolitan area. LEP patients refer to those who speak a primary language other than English and who cannot speak English at all or speak English so poorly that they cannot communicate in English without assistance. Language services, including the use of professional interpreters, are seen as a facilitator variable in conventional social science health care models because they help patients with limited English to communicate with health care providers. More effective communication between LEP patients and health providers is expected to improve LEP patients' access to, and quality of, medical care, leading to better health outcomes in the long run.

We evaluate the hypothesized role of interpreter services by conducting a secondary analysis of data derived from administrative records of two organizations, a large MCO and its contractor for interpreter services. Subjects for the study are 1,037 LEP members of the MCO. Over 80 percent speak Spanish, Vietnamese, Chinese, or Russian. The effects of interpreter services on health utilization of LEP patients are analyzed over a four-year period, from 1995 to 1999, using a quasi-experimental before-and-after research design. We compare several outcome measures two years before and after interpreter services were implemented in mid-1997. These include changes in total visits to health providers, use of emergency and urgent care facilities, cancellations of appointments, "no-show's" for appointments, and replacement of an "other" complaint code with specific complaint codes.

On the whole, findings provide support for the hypothesized role of interpreter services. LEP patients increased their health visits after the implementation of interpreter services. The increased utilization was larger for groups that can be considered to be most vulnerable to language barriers in accessing healthcare, such as the elderly, the poor, and patients who had below average health visits prior to the implementation of interpreter services. We also observed additional evidence of the hypothesized positive impact of interpreter services, including significant reductions in the number of "other" complaint codes used to describe LEP patients' reason for seeking medical care. This suggests that when interpreters are available, they assist LEP patients to communicate symptoms to health providers, resulting in more specific complaint codes being recorded (for example, codes for chest pain or stomach distress). This finding has important implications for the quality of care received by LEP patients.

Our evaluations of additional outcome measures yielded interesting but inconsistent findings. On some measures, for example, cancellations of appointments, the implementation of interpreter services was followed by what may be seen as positive changes. LEP patients increased their rate of cancellations of appointments. This effect of interpreter services represents a substantial reduction of costs associated with unkept appointments and wasted time of health providers. However, evaluations of other outcome measures failed to provide consistent support for the hypothesized role of interpreter services. For example, LEP patients' use of emergency and urgent care visits increased, instead of the expected decline following the introduction of interpreter services, and there were no significant reductions in the number of "no-show's" for appointments.

We also compared changes in the outcome measures for several sub-groups. We observed variations by gender, age, type of coverage, language group, and level of healthcare use prior to interpreter services. Lack of data prevented further analysis to unpack factors that could explain some of the sub-group variations. We are particularly interested in differences among language groups because these differences highlight the diversity of the LEP population. For example, language group differences are associated with many factors that are implicated in health status and use, including level of healthcare in countries of origin, cultural backgrounds and attitudes regarding healthcare, and immigration histories and experiences in the United States. It is clear that additional research is needed to examine how such factors interact with interpreter services to affect LEP patients' healthcare use and quality of care. In addition, while secondary data represent a unique opportunity for such research, our analysis was also constrained by data limitations. Future research could combine secondary with primary data to yield a more comprehensive analysis of the role of interpreter services on LEP patients' access to healthcare.

Sharon M. Lee, PhD
Professor and Director of Graduate Studies
Department of Sociology
Portland State University
Portland, OR 97207-0751
Phone: 503-725-3962
Fax: 503-725-3957
E-mail: lees@pdx.edu

Sharon Lee has a BA in sociology and psychology from the University of Rochester and a PhD in sociology from Princeton University. Her research focuses on population, immigration, race and ethnicity, and language and cultural diversity and healthcare. Recent research includes "Do Asian American faculty face a glass ceiling in higher education?" (American Educational Research Journal, 2002); "Recent trends in intermarriage and immigration and their effects on the future racial composition of the US population" (Russell Sage Foundation, 2002); "Patients who don't speak English: improving language minorities' health care with professional interpreters" (Final Report, Office of Minority Health/DHHS, 2001); and "Using the new racial categories in the 2000 Census" (Annie E. Casey Foundation, 2001). She is currently studying how cultural backgrounds influence foreign-born Asian women's health attitudes, behavior, and experiences. She is on the Census Advisory Committee of Professional Associations, the American Sociological Association's Race Task Force, and the Steering Committee, Scholars' Network, Hablamos Juntos.

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