Among patients served by the safety net healthcare system of San Francisco, patients speaking languages other than English attended scheduled gastroenterology clinic appointments at higher rates than English speakers. Although other variables contributed to attendance rates, language was the variable most highly associated with attendance.
We chose a priori
to focus on the role of language and race/ethnicity for several reasons. These patient-related variables are of sufficient significance to merit inclusion as a prominent component of Healthy People 2010, 40
because non-English speakers and nonwhite patients have been repeatedly found to experience significant barriers to healthcare resulting in reduced healthcare access. Because all the patients in our population have healthcare access, we wanted to determine whether barriers to clinic attendance also existed on the basic of language and race/ethnicity. Multiple inputs, including measures of socioeconomic status, language, transportation, insurance status, and psychiatric comorbidities likely contribute to clinic attendance, and we included many of these in our analyses. We did not intend to identify a causal role for language or race/ethnicity in determining clinic attendance rates, but sought to determine whether these were associated with clinic attendance. The identification of groups at higher risk of nonattendance may facilitate development of interventions to improve attendance, which could increase clinic efficiency and improve patient outcomes.
We found other studies of race/ethnicity and language to be of limited applicability to safety net populations, since most have not been performed among these specific populations. In other studies, there are significant differences in income and other measures of socioeconomic status between English and non-English speakers and between whites and nonwhites. 15,16,17,19,20
The magnitude of such differences in our population was small (for example, mean monthly income was $734 for English speakers versus $864 for non-English speakers, and $761 for whites versus $801 for nonwhites), and we adjusted for these in the multivariable analyses.
Our results differ from most prior studies of language, which document lower rates of healthcare access and utilization among non-English speakers compared with English speakers.19,20,21,22,23
Differences in our study population compared with other studies of healthcare access and utilization may partially explain our findings, because our study was undertaken within a safety net healthcare setting. Our findings may reflect differences in the selective forces that lead English speakers and non-English speakers to seek care in a safety net healthcare system. Non-English speakers are more likely than English speakers to be first-generation immigrants.41
An individual who successfully immigrates to the United States may have beliefs, practices, and social networks that helped them navigate the complex immigration system and a new country of residence (the “healthy immigrant effect”42
), and those factors may facilitate attendance at clinic appointments. Such social networks might also provide practical assistance with appointment-related tasks such as reminding patients of appointments and providing transportation and child- or elder-care. Conversely, English speakers in our study had significantly higher rates of homelessness, joblessness, substance abuse, and mental illness. None of these variables remained significant in the multivariable analyses (either independently or when constructed as a composite socioeconomic status variable), but taken together, they may represent higher levels of marginalization among English speakers compared with non-English speakers, which may contribute to lower clinic attendance rates.
Differences in our research question compared with prior studies may also explain our distinct findings. Most studies evaluate differences in access
to healthcare among different patient groups. As a recent example for comparison, Ananthakrishnan et al studied colorectal cancer screening in Medicare beneficiaries, comparing rates of screening in white versus nonwhite patients.18
To receive screening, patients had to have a provider who offered screening, patients had to schedule an appointment, and they had to attend the appointment and receive screening; it was not possible to separate patient, provider, and systems related factors that affected utilization of colorectal cancer screening. Our study, alternatively, looked at the more specific question of what patient factors were associated with attendance at scheduled gastroenterology clinic appointments among patients with established healthcare access and a scheduled clinic appointment. The presence of a primary care provider and an established appointment in the gastroenterology clinic minimized access barriers and systems related factors that have been the focus of other studies. Referrals were reviewed and judged to be appropriate by both a primary care provider and a gastroenterologist. This minimized inappropriate referrals and provider related factors that may affect other studies. Our more focused analysis may therefore have revealed patient related factors affecting subspecialty clinic attendance that were previously obscured by systems and provider related factors relating to healthcare access
, and this may explain the uniqueness of our findings.
SFGH has employed multiple efforts to improve healthcare access among non-English speakers and has won several awards for their interpreter services. Many employees, including front desk staff, nurses, and physicians, speak Spanish, Chinese dialects, and other non-English languages. Educational materials and forms are available in multiple languages. SFGH has one of the most comprehensive interpreter services in the nation, including a large trained interpreter staff, video medical interpreters, and phone interpreter services. Many clinics are located in neighborhoods where non-English speakers live, and these often employ persons from similar racial/ethnic groups to the populations that utilize them. All of these efforts may increase the attractiveness of the SFGH system to non-English speakers, and this may partially account for their higher attendance rates.
Because the patient population in which we performed our study is highly selected, our results are not universally generalizable, but may be generalizable to other safety net systems in diverse urban communities. We evaluated only a single clinic type, but our findings may be applicable to other subspecialty clinic types, especially those within safety net healthcare populations. Because all referrals were evaluated by a single gastroenterologist (HFY), selection bias may affect our results, but it is unclear how this would occur on the basis of language. All patients were sent notification of their appointment date and time by telephone and/or mailed postcards, but we were unable to determine which patients actually received notification, and there was no mechanism to determine reasons for missed appointments. We were unable to systematically evaluate reasons for, or urgency of, patient referral, owing to lack of a standardized categorization scheme. Patients with urgent or symptomatic reasons for referral might be more likely to attend appointments, but it is not clear how this would relate to language.
Subspecialty care may improve outcomes for specific diseases when compared with generalist care and may lower mortality rates among patients receiving both subspecialty and general care compared with either alone. 43,44
Gastroenterology is a limited subspecialty resource throughout the United States, and with supply expected to further decrease among vulnerable patient populations, 8
it is vital that attendance at scheduled appointments be optimized in these patient groups. Even when applied to other, more privileged populations, our study underscores the importance of evaluating which patients attend clinic appointments and which patients fail to attend, so that the efficiency and quality of subspecialty healthcare provided may be increased.