Spanish-speaking patients who communicated through an interpreter and who did not have an interpreter when they thought one was necessary were significantly less likely to be given a referral for a follow-up appointment after an emergency department visit. The lower rate of referral for a follow-up appointment for these groups was consistent for all discharge diagnosis categories: new, specific diagnosis (e.g., cholelithiasis); descriptive diagnosis (e.g., low back pain); exacerbation of a previous medical problem (e.g., asthma); and even for those patients for whom a clear cause of their symptom was not identified by the examining physician (e.g., abdominal pain of unknown cause).
Previous studies have shown that Hispanic patients are treated differently from other patients. Todd et al. found that Hispanic patients with isolated long-bone fractures were twice as likely to not receive any pain medication at the time of their emergency department presentation.11
These differences in analgesic practice were not explained by differences in physicians' assessments of patients' pain; physicians assessed the severity of pain for Hispanics to be similar to that for non-Hispanic whites.16
Similarly, Cleeland et al. reported that Hispanic patients with cancer were less likely to have adequate analgesia and reported less pain relief than whites.17
Our results are consistent with these studies and suggest that language barriers may account for much of this variation. We found no difference in care patterns between whites and native English-speaking Latinos or Latinos who spoke Spanish and said they communicated adequately with their physician without the aid of an interpreter.
There are several possible explanations for why patients who experienced language barriers were less likely to be given a referral for follow-up appointments. Physicians may have had less understanding of the full nature of patients' problems due to communication problems. Similarly, it is possible that when physicians are faced with language barriers, they are more likely to forget to refer the patient for follow-up because they are struggling with the other details of the care plan. A physician may also need to call an interpreter back to explain follow-up appointments, and this could act as a psychological barrier for physicians to give referrals to patients with limited English proficiency.
The lower referral rate for patients who experienced language barriers could also partly result from some physicians having the perception that Spanish-speaking patients will be less likely to successfully complete their follow-up appointment owing to poverty, low educational attainment, lack of a telephone in the home, or lack of health insurance. As a consequence, they may think that arranging a follow-up appointment is futile. This study does not support such a belief. There was no difference in appointment compliance according to race or ethnicity, language, or interpreter use. Finally, it is possible that the lower referral rate for these groups was due to more overt bias against Spanish-speaking patients. The study was conducted a few months prior to passage of Proposition 187 in California,18
which requires publicly funded health care facilities to deny care to illegal immigrants and to report them to government officials. Although this study was conducted prior to passage of Proposition 187, the attitudes that allowed its passage were clearly dominant in the community at the time this study was conducted. These attitudes could have affected physicians' decision to arrange follow-up care. We did not obtain information regarding patients' citizenship because of the sensitive nature of this topic and our desire to follow patients over time. Therefore, our study could not determine whether citizenship affected referral rates for follow-up appointments.
It is also possible that the lower rate of referral for follow-up care was due to patient behaviors. When faced with communication problems, patients may be less willing to question physicians about the need for follow-up care or insist that such an appointment be arranged. However, the lower referral rate for patients who experienced language barriers was present even for patients who had a new diagnosis established and for those who were discharged from the emergency department without a definitive explanation of their symptoms. In these situations, referrals for follow-up appointments are routine, as shown by the high rate of referral for follow-up appointments in this study. Thus, it seems unlikely that patient attitudes and behaviors explain our findings.
In light of the communication problems faced by patients who had an interpreter and those who did not have an interpreter when they thought one was necessary, it is surprising that there was no difference in the knowledge of follow-up appointments at the time of the second interview. There are several possible explanations for this. First, all patients are given discharge instruction by a nurse who is fluent in Spanish. Thus, although there may have been large communication barriers between physicians and patients in these groups, the discharge instructions should have been communicated clearly to patients in their own language. In addition, family members who are bilingual may serve as translators for discharge instructions. These factors may have counteracted the language barriers that were present during the medical examination.
It was also somewhat surprising that there was no difference in compliance with follow-up appointments. Our results differ from those of a previous study by Manson, who studied a group of patients with asthma and found that Spanish-speaking patients who did not have a language-concordant physician had lower compliance rates with follow-up appointments. However, there are important differences between that patient population and ours. Emergency department patients may have new symptoms that highly motivate them to complete their follow-up appointment. Moreover, patients discharged from the emergency department will be seeing a different physician than the one that cared for them in the emergency department. So, although patients may have been dissatisfied with the care they received in the emergency department, this may not affect their compliance with follow-up appointments at other care sites with different physicians.
There are several important limitations to this study. Only 12% of the patients who had an interpreter used the hospital interpreter, and the remainder used “ad hoc” interpreters such as family or hospital staff. Because the number of patients with a professional interpreter was too small to analyze separately, our findings cannot be generalized to settings that rely predominantly on professional interpreters. Although our multivariate analyses adjusted for demographics, insurance, socioeconomic status, self-reported overall health, and discharge diagnosis category, there may have been other unmeasured confounding variables. We did not determine physicians' attitudes towards Spanish-speaking patients or their awareness of cross-cultural issues. Our methods may not have adequately adjusted for differences in the types of medical problems precipitating an emergency department visit for Spanish-speaking and English-speaking patients. Although we adjusted for whether patients had a regular source of care and the type of regular source of care, it is still possible that the study groups had different continuity provider relationships that could affect referral rates and appointment compliance. We also do not know whether patients who did not receive referrals for follow-up appointments had worse health outcomes. In addition, this study was conducted at a single site, so we do not know the generalizability of our findings to other sites. Because we enrolled patients with nonurgent medical problems, our findings also may not be generalizable to more severely ill patients.
Despite these limitations, our findings add to a growing body of literature suggesting that Latino patients are treated differently that non-Latino whites11,14,15
and raise questions about whether this could be attributable directly to language barriers. Further studies are necessary to determine whether Latino patients with limited English proficiency are less likely to receive other types of medical care; whether care patterns differ because of communication barriers, lack of cultural awareness, or patient behaviors; and whether these differences can be reduced through programs that increase the availability of properly trained interpreters and teach physicians how to handle cultural and linguistic barriers to care.