Fellows journal Club
Article: Khan A, Yin HS, Brach C, Graham DA, Ramotar MW, Williams DN, Spector N, Landrigan CP, Dreyer BP; Patient and Family Centered I-PASS Health Literacy Subcommittee. Association Between Parent Comfort With English and Adverse Events Among Hospitalized Children. JAMA Pediatr. 2020 Dec 1;174(12):e203215.
Fellow: Kathryn Westphal, MD; Nationwide Children’s Hospital
Summary: Effective communication between a provider and patient is crucial to the delivery of safe, high-quality care. Therefore, pediatric patients with caregivers experiencing language barriers may be at increased risk of hospital adverse events (i.e. harm due to medical care). This study looked at the association between parents’ comfort speaking English and adverse events (overall and preventable) in hospitalized children on non-intensive care medical units through a multicenter prospective cohort design. Experiencing at least 1 adverse event occurred significantly more often in children whose parents expressed limited comfort with English (LCE) compared with children with parents expressing comfort with English (17.7% versus 9.6%). After controlling for potential confounding variables, children of parents who expressed LCE had more than double the adjusted odds of adverse events and preventable adverse events than children whose parents expressed comfort with English (adverse events aOR 2.1; 95% CI, 1.2-3.7; preventable adverse events aOR 2.3; 95% CI, 1.2-4.2).
Key Strengths: This study was strengthened by its multicenter design and the inclusion of a diverse parent population that spoke multiple languages, thereby increasing the generalizability of the results. Furthermore, the safety surveillance methodology employed to identify adverse events was more comprehensive compared to previous studies as it utilized family event reporting in addition to the conventional methods of reviewing medical records, clinician reports, and hospital incident reports. This rigorous approach to measuring adverse events addresses the concern of underreporting that other methods are subject to. The study also examined the subset of preventable adverse events, distinct from nonpreventable adverse events, which is useful when designing interventions.
Limitations or flaws: Language-comfort data was collected through parent-self reporting, which is subject to potential reporting bias. It also did not assess limited English proficiency (LEP) which has been shown to be a more useful measure in evaluating language barriers and their associations with healthcare outcomes. A limitation to the application of results is the adjusted odds ratio does not tell us how frequently the problem occurs or the magnitude of risk, only that adverse events occurred more often in patients whose parents expressed LCE compared to those that speak English.
Major takeaway: In this multicenter study, 1 in 11 (8.8%) parents of hospitalized children expressed LCE. Despite the availability of interpreter services at all sites, their children had twice the odds of experiencing an adverse event compared with children of parents expressing comfort with English. This study’s results establish an association of language barriers with adverse events in hospitalized children, adding to the already known list of LEP-related disparities in healthcare quality.
How this article should impact our practice: This study should increase awareness that pediatric patients with parents experiencing language barriers are prevalent and particularly vulnerable to harm in the inpatient setting. There are many potential contributors to the association, but interventions could include accurately and consistently identifying language assistance needs, developing standards around inpatient interpreter use, empowering families and interpreters to voice safety concerns, and combating provider implicit bias and racism. Hospitalists need to invest in further research to understand this complex problem and develop targeted interventions to better care for this high-risk population.
Fellow: Kathryn Westphal, MD; Nationwide Children’s Hospital
Summary: Effective communication between a provider and patient is crucial to the delivery of safe, high-quality care. Therefore, pediatric patients with caregivers experiencing language barriers may be at increased risk of hospital adverse events (i.e. harm due to medical care). This study looked at the association between parents’ comfort speaking English and adverse events (overall and preventable) in hospitalized children on non-intensive care medical units through a multicenter prospective cohort design. Experiencing at least 1 adverse event occurred significantly more often in children whose parents expressed limited comfort with English (LCE) compared with children with parents expressing comfort with English (17.7% versus 9.6%). After controlling for potential confounding variables, children of parents who expressed LCE had more than double the adjusted odds of adverse events and preventable adverse events than children whose parents expressed comfort with English (adverse events aOR 2.1; 95% CI, 1.2-3.7; preventable adverse events aOR 2.3; 95% CI, 1.2-4.2).
Key Strengths: This study was strengthened by its multicenter design and the inclusion of a diverse parent population that spoke multiple languages, thereby increasing the generalizability of the results. Furthermore, the safety surveillance methodology employed to identify adverse events was more comprehensive compared to previous studies as it utilized family event reporting in addition to the conventional methods of reviewing medical records, clinician reports, and hospital incident reports. This rigorous approach to measuring adverse events addresses the concern of underreporting that other methods are subject to. The study also examined the subset of preventable adverse events, distinct from nonpreventable adverse events, which is useful when designing interventions.
Limitations or flaws: Language-comfort data was collected through parent-self reporting, which is subject to potential reporting bias. It also did not assess limited English proficiency (LEP) which has been shown to be a more useful measure in evaluating language barriers and their associations with healthcare outcomes. A limitation to the application of results is the adjusted odds ratio does not tell us how frequently the problem occurs or the magnitude of risk, only that adverse events occurred more often in patients whose parents expressed LCE compared to those that speak English.
Major takeaway: In this multicenter study, 1 in 11 (8.8%) parents of hospitalized children expressed LCE. Despite the availability of interpreter services at all sites, their children had twice the odds of experiencing an adverse event compared with children of parents expressing comfort with English. This study’s results establish an association of language barriers with adverse events in hospitalized children, adding to the already known list of LEP-related disparities in healthcare quality.
How this article should impact our practice: This study should increase awareness that pediatric patients with parents experiencing language barriers are prevalent and particularly vulnerable to harm in the inpatient setting. There are many potential contributors to the association, but interventions could include accurately and consistently identifying language assistance needs, developing standards around inpatient interpreter use, empowering families and interpreters to voice safety concerns, and combating provider implicit bias and racism. Hospitalists need to invest in further research to understand this complex problem and develop targeted interventions to better care for this high-risk population.
Fellow: Kathryn Westphal, MD; Nationwide Children’s Hospital
Current Research: I have an interest in improving the quality of care for hospitalized infants. My fellowship research project is assessing the impact of the COVID-19 pandemic on neonatal health by describing changes in neonatal utilization of acute care services during the pandemic. I am also part of the Brief Resolved Unexplained Event Research and Quality Improvement Network.
Future Plans: I’d like to be a hospitalist at an academic center where I can continue incorporating clinical care, research, and medical education into my career.
Fun Fact: In high school, I juggled fire in my school’s talent show. As part of a summer job during college, I took my talent to the water and started juggling tennis balls while waterskiing in a weekly ski show.
Current Research: I have an interest in improving the quality of care for hospitalized infants. My fellowship research project is assessing the impact of the COVID-19 pandemic on neonatal health by describing changes in neonatal utilization of acute care services during the pandemic. I am also part of the Brief Resolved Unexplained Event Research and Quality Improvement Network.
Future Plans: I’d like to be a hospitalist at an academic center where I can continue incorporating clinical care, research, and medical education into my career.
Fun Fact: In high school, I juggled fire in my school’s talent show. As part of a summer job during college, I took my talent to the water and started juggling tennis balls while waterskiing in a weekly ski show.
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