Our study found that the English proficiency question used in the U.S. Census is able to identify most patients who cannot communicate effectively with their physicians in English. While the cutoff used in the U.S. Census to define LEP as anyone who reports speaking English less than “very well” was the most sensitive measure for identifying all of the patients who reported they were unable to communicate effectively with their physicians, it was also the least specific. This lower specificity could lead to misclassification of some patients as LEP who are, in fact, able to effectively communicate in English with their physicians. This type of misclassification might lead to costly language assistance resources being deployed unnecessarily. On the other hand, the higher specificity along with the lower sensitivity afforded by use of the mid-threshold of speaking English less than “well” on the Census-LEP question may result in misclassifying LEP patients as English speakers and not offering them language assistance, which in turn might lead to poor communication or medical errors.
Our composite variable of likelihood of benefit from language assistance was derived from the Census English proficiency question and a language preference for medical care item. This composite variable maintained very high sensitivity, while significantly improving specificity compared to the less than “very well” threshold for the Census-LEP item alone. This suggests that adding a second question on language preference for medical care after screening with the U.S. Census question, can both inclusively identify patients who might benefit from language assistance, while maximizing the appropriate use of limited language resources. In practice, use of both items allows health care organizations and clinicians to err on the side of caution and patient safety while maintaining efficiency of service delivery. Thus, our findings support the use of both items in clinical settings to accurately identify patients who are most likely to benefit from language assistance, and to screen out those who are unlikely to benefit.
Our findings further demonstrate the importance of addressing language needs for the provision of high quality, patient-centered healthcare. In our study, it was apparent that self-reported lack of English fluency, restricted patients’ ability to communicate effectively with their physicians. Those who rated their skills in English as speaking less than “well” were substantially more likely to report problems discussing their symptoms or understanding their physicians’ recommendations in English, two processes fundamental to receiving quality healthcare. Use of single item or composite measures such as those described in this study is consistent with quality of care indicators developed by the National Committee on Quality Assurance (NCQA), the Agency for Healthcare Quality and Research (AHRQ), and the Foundation for Accountability (FACCT), which emphasize the importance of language preferences in assessing the quality of health care among diverse populations.32
Furthermore, the Department of Health and Human Services’ Office of Minority Health supports collection in clinical settings of data on English proficiency and need for an interpreter.33
Identification of those patients who would benefit from language assistance—whether in the form of fluent, language concordant physicians or in the form of professional interpreter services—is a necessary step to optimizing patient-centered care for LEP individuals.
Our study was limited by the small number of participants who reported speaking English “well”, thereby limiting our capacity to test the composite variable “benefit from language assistance”. A larger sample from more clinical sites would have allowed for greater precision in the performance of the questions. Nonetheless, our study stands out among studies of language barriers for including both inpatient and outpatient clinical sites. Both the language indicators and effective communication measures were based on self-report rather than objective measures of English proficiency and communication, making it possible that our study under- or over-estimated participants’ English language communication abilities in the medical setting. However, the high correlations between the Census question and each of our effective communication questions supports the validity of these measures as indicators of need for language assistance in clinical settings. The correlation of the Census measure is highest with the ability to discuss symptoms with physicians item. It is possible that the differences in responses to the two effective communication questions (discussing symptoms and understanding doctors’ recommendations) indicate that some participants did not understand the meaning or intent of these questions. Alternatively, these differences could reflect that both the Census and the discuss symptoms items ask about spoken language, while the understanding doctors item asks about aural comprehension.
In conclusion, our findings support the use of simple, feasible, and standardized measures in clinical settings to identify LEP patients who should be offered language assistance, preferably in the form of either fluent language concordant clinicians and staff, or professional interpreters. Our data support use of the U.S. Census English proficiency item with a high-threshold of less than “very well” as a screening question, followed by a question about language preference for receipt of medical care for the subset of patients who report speaking English “well”. We recommend that health care systems and clinicians adopt a standardized method for identification of LEP patients and propose that the algorithm used in this study may meet this standard. It is our hope that this algorithm, when applied in a systematic manner, can be used to monitor the impact of providing language assistance and improve the quality of care for all limited English proficient patients.