Racial/Ethnic Disparities and Patient Safety Thursday, November 15, 2007 12:00 – 1:00 p.m. ET.

Racial/Ethnic Disparitiesand Patient Safety

Thursday, November 15, 200712:00 – 1:00 p.m. ET

Moderator: Erin R. Stucky, MD, FAAPPediatric HospitalistChildren’s Specialists of San DiegoRady Children’s HospitalSan Diego, California

This activity was funded through an educational grant from the Physicians’

Foundation for Health Systems Excellence.

Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid

The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004).

The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.

All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity.

The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.

DISCLOSURES Activity Title: Safer Health Care for Kids - Webinar Racial/Ethnic Disparities and Patient Safety Activity Date: November 15, 2007

DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing

health care goods

or services)

Nature of Relevant Financial

Relationship(s) (If yes, please list: Research Grant,

Speaker’s Bureau, Stock/Bonds

excluding mutual funds, Consultant,

Other - identify)

CME Content Will Include

Discussion/ Reference to Commercial

Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses of Products

AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or

demonstrate pharmaceuticals and/or medical devices that are not approved

Glenn Flores, MD, FAAP

No No No No

DISCLOSURESSAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.


(*Entity producing health care goods

or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s

Bureau, Stock/Bonds excluding mutual funds,

Consultant, Other - identify)

CME Content Will Include Discussion/

Reference to Commercial Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses

of Products AAP CME faculty are required to

disclose to the AAP and to learners when they plan to discuss or


Karen Frush, MD, FAAP (PAC Member)

No No No No

Uma Kotagal, MD, MBBS, MSc, FAAP (PAC Member)

No No No No

Christopher Landrigan, MD, MPH, FAAP (PAC Member)

No No No Not sure

Marlene R. Miller, MD, MSc, FAAP (PAC Chair)

No No No No

Paul Sharek, MD, MPH. FAAP (PAC Member)

No No No No

Erin Stucky, MD, FAAP (PAC Member)

No No No No

Nancy Nelson (AAP Staff) No No No No

Melissa Singleton, MEd (Project Manager – AAP Consultant)

No No No No

Junelle Speller (AAP Staff) No No No No

Rev 9/2007

DISCLOSURESAAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME) DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.


(*Entity producing health care goods

or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s

Bureau, Stock/Bonds excluding mutual funds,

Consultant, Other - identify)

CME Content Will Include Discussion/

Reference to Commercial Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses

of Products AAP CME faculty are required to

disclose to the AAP and to learners when they plan to discuss or


Ellen Buerk, MD, FAAP

No No No No

Meg Fisher, MD, FAAP

No No No No

Robert A. Wiebe, MD, FAAP

No No Not sure No

Jack Dolcourt, MD, FAAP

No No No No

Thomas W. Pendergrass, MD, FAAP

No No No No

Beverly P. Wood, MD, FAAP No No No No

CME CREDIT

The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAP designates this educational activity for a

maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This activity is acceptable for up to 1.0 AAP credit.

This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

OTHER CREDIT

This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633.

The American Academy of Physician Assistants

accepts AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .

Glenn Flores, MD, FAAPProfessor of Pediatrics and Public HealthDirector, Division of General PediatricsThe Judith and Charles Ginsburg Chair in PediatricsUT Southwestern Medical CenterDallas, Texas

Learning Objectives

Upon completion of this activity, you will be able to:

Discuss racial/ethnic disparities in pediatric patient safety and summarize priorities and unanswered questions in the field.

Describe a new conceptual model for understanding racial/ethnic disparities in pediatric patient safety.

Apply this model to improve patient safety for racial/ethnic minority children.

Glenn Flores, MD, FAAP Professor and Director, Division of General Pediatrics

Judith and Charles Ginsburg Chair in Pediatrics University of Texas Southwestern Medical Center

Children’s Medical CenterDallas, TX

Reference: Pediatric Clinics of North America

2006;53:1197-1215

Racial/Ethnic Disparities

and Patient Safety

Background Number of racial/ethnic minority children will exceed

number of non-Latino white children in US by 2030 Indeed, from 2030-2050, non-Latino white population will

contribute nothing to nation’s population growth because it will decline in size,in contrast to African-American population, which will double

between 1995 and 2050 Latino population, which will add more people to US

every year after 2020 than all other racial/ethnic groups combined

Background Rapid growth of minorities in US makes it increasingly

likely each year that healthcare providers will care for minority patients

Nevertheless, very little known about racial/ethnic disparities in patient safety, particularly when it comes to children. For example, in landmark Institute of Medicine (IOM) report,“To Err is Human:” Neither race nor ethnicity mentioned Linguistic issues mentioned very briefly in 3 sentences,

and only in reference to access to care or general recommendations

Webinar Goals Review what we know about racial/ethnic

disparities in pediatric patient safety and summarize priorities and unanswered questions in this field

Describe new conceptual model for racial/ethnic disparities in patient safety

Identify what can be done to improve patient safety for racial/ethnic minority children

Helpful Definitions

Because substantial variation exists in patient safetyterminology, it’s useful to define certain terms Medical error

Act of commission or omission that substantively increases risk of a medical adverse event

Can result from failure of planned action to be completed as intended (i.e., mishap or error of execution), or use of wrong plan to achieve aim (i.e., error of planning)

Definitions Error of commission

Medical error resulting in inappropriate increased risk of iatrogenic adverse event(s) from receiving too much or hazardous treatment (overuse or misuse)

Includes quality problems such as excessive medication doses, contraindicated treatments, giving wrong medication, or iatrogenic risk from unneeded interventions

Error of omission Medical error resulting in an inappropriate increased risk of disease-

related adverse event(s) from receiving too little treatment (underuse)

Includes quality problems such as delayed diagnoses, subtherapeutic medication doses, and failure to provide indicated treatments

Definitions Medical adverse event

Incident resulting in medical injury, complication, worsening health outcomes, or perceived harm (either physical or emotional distress)

Can occur despite appropriate care (such as recognized complications of an intervention or resulting from the person's underlying disease) or can be caused by errors of omission or commission

Definitions Racial/ethnic disparity

Any difference in health or healthcare among different racial/ethnic groups (using whites as reference group)

Linguistic disparity Any difference in health or healthcare between those

whose primary language is English (the reference group) and those whose primary language is not English and who are limited in English proficiency (LEP, defined as self-rated English speaking ability of less than“very well”)

Review of Medical Literature Systematic review performed of representative sample

of published literature on racial/ethnic disparities in pediatric patient safety to Identify what’s known and not known about

racial/ethnic disparities in pediatric patient safety Summarize urgent priorities and unanswered

questions Medline search of > 40 years of research (from 1966 to

2006) published in 14 major journals Search criteria yielded 323 articles

Review of Medical Literature Very few pediatric patient safety articles have

examined racial/ethnic disparities Of 323 pediatric patient safety articles in systematic

review, only 9 (3%) included race/ethnicity in analyses

Only 1 of 323 studies (0.3%) specifically focused on racial/ethnic disparities in patient safety (although it included both children and adults)

4 studies examined data for both children and adults, but did not perform separate analyses for children by race/ethnicity

Key Findings from Literature: Disparities in Birth Trauma

Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed significantly higher risk of birth trauma in minority newborns. Compared with white newborns, adjusted odds of birth trauma

1.5 times greater (95% confidence interval [CI], 1.5-1.6) for African-American newborns

1.2 times greater (95% CI, 1.1-1.2) for Latino newborns 1.2 times greater (95% CI, 1.1-1.2) for newborns in other racial/ethnic

groups Of note, birth trauma by far most common adverse medical event,

accounting for over 36,000 events and event rate of 154 per 10,000 discharges, exceeding event rate (100 per 10,000 discharges) for all 10 other adverse medical event categories combined

Newborns with birth trauma documented to have almost triple in-hospital mortality rate of newborns without birth trauma

Key Findings: Disparities in Infection Due to Medical Care

Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed

African-Americans, Asians/Pacific Islanders, and Latinos had significantly higher rates than whites of infections due to medical care and of post-operative sepsis

Analysis of Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample documented

African-Americans had higher risk than whites of postoperative infectious complications, including sepsis, and infections following infusion, injection, and transfusion

Latinos had somewhat higher risk than whites of postoperative septicemia and infection due to medical care

Key Findings: Disparities in Postoperative Adverse Medical Events

Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed that, compared with white children,

African-American children had significantly higher rates of postoperative hemorrhage/hematoma, decubitus ulcers, and pulmonary embolus or deep vein thrombosis

Asians/Pacific Islander children had significantly higher rate of postoperative hemorrhage/hematoma

African-Americans, Asians/Pacific Islanders, and Latinos had significantly higher rates of postoperative respiratory failure and physiologic/metabolic derangement

Key Findings: Disparities in Postoperative Adverse Medical Events

Analysis of Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample documented that, compared with white children, African-American children had higher risk of

decubitus ulcers, infection following infusion, injection, transfusion, postoperative physiologic and metabolic derangements, and thromboembolism

Latino children had somewhat higher risk of postoperative septicemia, respiratory failure, and physiologic and metabolic derangements

Racial/Ethnic Differences in Perceived Error Severity & Reporting

Survey of 499 parents in an ED revealed racial/ethnicdifferences in parental perceptions of medical error severityand parental preferences for reporting medical errors to adisciplinary body. Compared with white parents, African-American parents significantly more likely to rate 4

medical error scenarios as more severe (62% vs. 49%, respectively; P < .01)

African-American parents significantly more likely to want party responsible for medical error to be reported to disciplinary organizations (50% vs. 33%; P < .01)

Difference persisted even after adjustment for relevant covariates (relative risk, 1.29; 95% CI,1.02-1.58).

Language Barriers and Higher Risk of Adverse Events

Case-control study of 572 children hospitalized at achildren’s hospital documented disparities in risk ofadverse medical events for children whose familiesrequested Spanish interpreters Patients and families requesting Spanish

interpreters had more than twice the odds of serious medical events (odds ratio, 2.26; 95% CI, 1.06-4.81) compared with thosenot requesting interpreters

Unanswered Questions: Disparities and Patient Safety

Many unanswered questions remain about racial/ethnic disparities in pediatric patient safety

More research needed on racial/ethnic disparities in birth trauma and reasons for disparities

Greater insight needed about minorities’ greater risk for infections due to medical care and for postoperative bleeding, sepsis, respiratory failure, and physiologic/metabolic derangement

Not enough known about racial/ethnic disparities in pediatric patient safety in outpatient setting

Unanswered Questions: Disparities and Patient Safety

More research needed on association of language barriers with medical errors and adverse medical events

When medical errors and adverse medical events occur, need to know more about minorities’ perceptions and preferences regarding severity, disclosure, reporting, disciplinary response, and legal action

New Conceptual Model: Racial/ Ethnic Disparities in Patient SafetyNew conceptual model proposed to provide more comprehensive,patient- and family-centered framework for understandingdisparities in patient safety. Five components of model include: Higher prevalence of known risk factors for medical errors in

minorities Medical errors of omission and deviations from optimal practice

frequent and particularly important for minorities Adverse medical event definitions often fail to include important

minority patient views on what constitutes harm Language barriers result in higher risk of medical errors and adverse

medical events Data collection systems for identifying and monitoring disparities in

patient safety often insufficient or absent

Higher Prevalence of Risk Factors for Medical Errors in Minorities1st component of model posits minority children at higherrisk for patient safety disparities due to high prevalence ofknown risk factors for medical errors in minority children Youngest hospitalized children (0-1 year olds) consistently and

significantly more likely to experience patient safety events and youngest children (0-3 years old) at greatest risk for outpatient medication errors

Minorities comprise substantially larger proportion of youngest children (0-5 years old) in US than in general US population: 43% of 20 million 0-5 year olds non-white, compared with 32% of US population of all ages

Thus, youngest US children both more likely to be minorities and to be at greater risk for medical errors and adverse medical events

Higher Prevalence of Risk Factors for Medical Errors in Minorities

Neonates in the Neonatal Intensive Care Unit (NICU) experience highest rates of medication errors and potential adverse drug events of any age group of hospitalized children, and at rates exceeding those of general adult population

African-Americans continue to have substantially higher rates of premature, low birth weight, and very low birth weight infants, accounting for their disproportionate representation among NICU admissions (> ½ of NICU admissions African-American)

Thus, African-American infants at high risk for medication errors and potential adverse drug events because of disproportionately greater risk of NICU admission

Higher Prevalence of Risk Factors for Medical Errors in Minorities

Receiving care in ED has been shown to be associated with higher risk of adverse medical events

Multiple studies document that minority children make significantly more ED visits than white children

Importance of Errors of Omission & Deviation from Optimal Practice

Recent work has called attention to importance of medical errors of omission, in which receiving too little treatment (under-use) results in inappropriate increased risk of disease-related adverse medical events

One study found omission errors accounted for 96% of all medical errors

Most common categories of omission errors include obtaining insufficient information from histories and physicals, inadequacies in diagnostic testing, and patients not receiving needed medications

We propose that medical errors of omission a frequent and important patient safety issue for racial/ethnic minority children, in comparison with white children


Multiple studies document medical errors of omission among minority children and sometimes serious adverse medical events they cause

Language barriers documented to frequently result in insufficient information from histories and physicals for Latino pediatric patients, including

Omission of important information about drug allergies, past medical history, and chief complaint

Critical distortions in psychiatric symptoms Misinterpretations resulting in quadriplegia and inappropriate

placement of children in social services custody for erroneous diagnosis of child abuse


Example of inadequacies in diagnostic testing: study of children presenting to children’s hospital ED which found Latino children significantly less likely than white children to undergo two or more diagnostic tests or to have x-rays done

Several studies both in US and UK document substantial racial/ethnic disparities in pediatric asthma treatment, such as significantly lower odds of minorities receiving β2 agonists and anti-inflammatory medications


Stark example of medical errors of omission: study of white psychotherapists in which 2 case histories presented that were identical except for race of adolescent boy (white vs. African-American)

Compared with white adolescent’s case, psychotherapists gave significantly lower ratings for African-American adolescent for clinical significance of 8 of 21 pathological behaviors

White therapists less distressed about African-American adolescent beating his girlfriend, stealing cars, mistrusting interviewer, and hating his mother

Supports hypothesis that mental disorders in African-American adolescents under-diagnosed because their pathological behaviors rated less severely


Importance of medical errors of omissions in patient safety raises broader conceptual issue: medical error should be defined as any deviation from optimal practice

This critical adjustment in definition of medical error allows powerful systems approach to error prevention in which an error viewed as a system failure that requires system adjustment

Including deviation from optimal practice as a medical error also underscores crucial interrelationship of patient safety, quality of care, and racial/ethnic disparities


Deviation from optimal practice associated with higher risk of serious adverse medical events for minorities and may contribute substantially to disparities

Study of over 74,000 very low-birth-weight (VLBW) infants in Vermont Oxford Network revealed minority-serving hospitals (those with >35% African-American infants) had significantly higher adjusted infant mortality rates for both African-American and white infants, vs. hospitals serving <15% of African-American infants

Study of 51 New York hospitals documented hospitals with >80% minority discharges had double adjusted odds of adverse events due to negligence (injuries due to interventions that were inappropriate or did not meet standard of care), compared with hospitals with lower proportions of minority discharges

Patient Safety Definitions Often Fail to Include Minority Views on What Harm Is

Research reveals definitions of medical errors and adverse medical events often fail to capture what constitutes harm and error from perspectives of minority patients and families

Qualitative study of white and African-American patients about preventable incidents resulting in perceived harm in primary care and primary care of their children revealed 70% of harms psychological

For African-Americans, among most important incidents: those in which racism or prejudice occurred

Findings suggest patients and families view breakdowns in patient-physician relationship as more prominent medical errors than technical errors in diagnosis and treatment

Failure to accommodate this patient-oriented definition of medical error and harm, particularly regarding perceived bias/prejudice towards minority patients, could lead to ongoing but undetected disparities in patient safety

Language Barriers & Higher Risk of Errors & Adverse Events

Evidence documents language barriers resultin higher risk of medical errors andadverse medical events

Study of pediatric encounters with LEP Latino children and their families revealed 63% of all errors by medical interpreters had potential or actual clinical consequences, with mean of 19 such errors per encounter

Errors committed by ad hoc interpreters (family members and friends) 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 in this study included Omitting questions about drug allergies Omitting instructions on dose, frequency, and

duration of antibiotics and rehydration fluids Adding that hydrocortisone cream must be applied to

entire body, instead of solely to a facial rash Instructing a mother not to answer personal

questions Omitting that a child already swabbed for a stool

culture Instructing a mother to put amoxicillin in both ears

for treatment of otitis media


Study of over 4,000 children seen in ED showed that,compared with English-proficient patients, LEP patientswho had either no interpreter or non-medical, ad hocinterpreters, had: Significantly higher incidence of having medical tests

done (OR, 1.5; 95% CI, 1.04-2.2) Higher test costs (mean difference = $5.73) Significantly greater likelihood of hospitalization

(OR, 2.6; 95% CI, 1.4-4.5) Significantly greater likelihood of receiving

intravenous hydration (OR, 2.2; 95% CI, 1.2-4.3)

Insufficient Data Collection Systems and Patient Safety Disparities

Disparities in patient safety cannot be identified and monitored if data collection systems fail to or inaccurately record patients’ race/ethnicity, primary language spoken at home, and English proficiency

Recent study revealed only 78% of US hospitals systematically collect data on race/ethnicity of patients and only 39% collect data on patients’ primary language

Just 27% of 1,000 hospitals surveyed, however, responded, so these proportions actually may be substantially lower

51% of hospitals collecting race/ethnicity data reported that admitting clerks determined patients’ race/ethnicity based on observation, a method which

Can result in high rates of inaccuracies, missing data, and classifications in “unknown” and “other” categories

Contradicts expert recommendations that such data be collected by patient self-report


Another recent survey of 500 US hospitals found that 78% collect patient race information, 50% collect patient ethnicity information, and 50% collect primary language information

Although recording language information highly variable across hospitals and rarely a required field

Survey non-response rate was 55%, so, as with aforementioned survey, these proportions actually may be substantially lower


These findings indicate that at least 22-50% of US hospitals collect no patient race/ethnicity data and 50-61% collect no primary language data

Unclear whether any hospitals routinely collect data on patients’ English proficiency, a measure that has been shown to be more useful for examining health outcomes

Such insufficiencies and absences in collection of data on race/ethnicity and language can result in failure to identify important patient safety disparities

Two Illustrative Examples: Asthma and Language Barriers

Pediatric asthma and language barrierstwo of clearest and most well researched examples of disparities inpediatric patient safety

Next few slides examine patient safety issues associated with asthma andlanguage barriers, using prior patient safety work and definitions as well ascomponents of proposed conceptual model

Pediatric Asthma and Patient Safety Disparities in pediatric asthma underscore important patient safety

issues and conceptual model components that may perpetuate patient safety disparities

Studies document high prevalence of certain risk factors for medical errors among minority children with asthma

Puerto Rican and African-American children experience greater asthma severity and complexity

Asthmatic children from both groups have significantly higher adjusted odds than white asthmatic children of suffering asthma attack in past year and experiencing more severe wheezing

African-American children substantially more likely than white children to be hospitalized for and die from asthma

Pediatric Asthma and Patient Safety Greater ED use another risk factor for medical errors

Several studies document African-American and Latino children significantly more likely to make asthma ED visits than white children

Substantial literature documents frequent errors of omission and deviation from optimal care for minority children with asthma. Studies demonstrate minority children with asthma significantly less likely than white children with asthma to receive prescriptions for

2 agonists Anti-inflammatory medications Medications and nebulizers for home use after hospital

discharge

Pediatric Asthma and Patient Safety Studies also document minority children with asthma subject to

medical errors of commission, exposing them to inappropriate increased risk of iatrogenic adverse events from receiving too much or hazardous treatment (i.e., overuse or misuse errors)

Among asthmatic children in UK, Afro-Caribbean asthmatic children had 8 times the odds and Indian subcontinent children 4 times the odds of asthmatic white children of receiving contraindicated antitussive prescriptions

African-American children with asthma in Washington state Medicaid system found to have significantly higher adjusted odds than white asthmatic children of receiving theophylline prescriptions, which likely is misuse error representing deviation from optimal therapy

Good News: Where There’s Cultural Competency, There’s High Quality

Recent study of 1,663 asthmatic children in 5 health plans in 3 states found practice sites with highest cultural competency scores have

Significantly lower patient under-use of preventive asthma medications(adjusted odds ratio of under-use = 0.15; 95% CI, 0.1-0.4)

Significantly better parent ratings ofquality of asthma care

(Lieu et al. Pediatr. 2004;114:e102-10)

Language Barriers and Patient Safety

Multiple studies document frequently serious medical errors and adverse events that can occur due to language barriers for limited English proficient (LEP) patients and their families who fail to get trained medical interpreter services

Those who need but don’t get interpreters have poor self-reported understanding of diagnosis and treatment plan and frequently wish healthcare providers explained things better

Ad hoc interpreters (family members, friends, untrained bilingual staff, and strangers from waiting room or street)

Misinterpret or omit up to ½ of all physicians’ questions More likely to commit errors with potential or actual clinical

consequences Have higher risk of not mentioning

medication side effects Ignore embarrassing issues when children interpret


Interpreter errors in mental health care

shown to result in Overemphasis of psychotic features Under-emphasis of affective components Underestimation of suicide risk Distortions of intellectual abilities, mental status, and

thought disorders Difficulty assessing ambivalent patient attitudes “Normalization” of pathological symptoms


Latino parents report lack of medical staff who speak Spanish resulted in poor medical care for 8% of children, misdiagnosis for 6% of children, inappropriate medications for 5%, and inappropriate hospitalizations for 1%

Children whose families request Spanish interpreters have more than double the odds of serious medical events compared with those not requesting interpreter

Study of pediatric ED visits demonstrated that, compared with English-proficient patients, LEP patients who had either no interpreter or non-medical, ad hoc interpreters had significantly higher incidence of having medical tests done, higher test costs, and significantly greater likelihood of hospitalization and receiving intravenous hydration


Multiple published case reports dramatically illustrate adverse medical events that can occur when language barriers present

Six-week-old infant admitted for an overdose of barbiturates due to a tenfold medication dosing error by an LEP mother who did not understand outpatient dosing instructions available only in English

Lack of medical interpreter resulted in delayed diagnosis of appendicitis that ultimately evolved into ruptured appendix, peritonitis, wound site infections, and 30-day hospital stay


2-year-old girl who sustained fractured clavicle by falling off her tricycle misdiagnosed as victim of child abuse due to misinterpretation of 2 words (“se pegó,” which can mean “she hit herself” or “she was hit”)

Girl and her sibling inappropriately subsequently placed in social services custody after LEP mother was asked to sign over voluntary custody using form only available in English

Misinterpretation of single word (“intoxicado”) by paramedics and ED staff resulted in comatose teen incorrectly being treated and admitted for 48 hours for drug overdose

Subsequently found to have ruptured cerebral artery, resulting in quadriplegia and $71 million legal settlement

Language Barriers andPatient Safety: Case

10-month-old girl taken to pediatrician’s office by her monolingual Spanish-speaking parents and infant diagnosed with iron-deficiency anemia. Pediatrician wrote following prescription in English:

Fer-In-Sol iron drops, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)

Parents took prescription to pharmacy. With no available interpreter, pharmacist attempted to demonstrate proper dosing and parents nodded in understanding. Prescription label on bottle written in English

Language Barriers and Patient Safety: Case

Parents administered medication at home and, within 15 minutes, 10-month-old vomited twice and appeared ill

Parents took her to nearest ED, where serum iron level 1 hour after ingestion = 365 mcg/dL (therapeutic levels: 60-180 mcg/dL)

Upon questioning, parents stated they had administered household tablespoon of medication, approximately 15 ml or 43 mg/kg (a 12.5-fold overdose)

Recent Research: Language Barriers, Prescriptions, and Pharmacies

Recent study of pharmacies in major metropolitan area

revealed 47% of pharmacies never/only sometimes can print non-

English-language prescription labels 54% never/only sometimes can prepare

non-English-language information packets 64% never/only sometimes can orally communicate

in non-English-languages 11% use patient family members/friends to interpret Only 55% satisfied with their

LEP patient communication

Conclusions Number of racial/ethnic minority children will exceed

number of non-Latino white children in US by 2030 But very little known about racial/ethnic disparities

in patient safety, particularly in children Review of medical literature revealed several

racial/ethnic disparities in pediatric patient safety, including Higher rates of newborn birth trauma Infections due to medical care Postoperative adverse medical events Greater likelihood of adverse events for hospitalized

children whose parents requested Spanish interpreter

Conclusions Proposed new conceptual model for understanding

racial/ethnic disparities in patient safety includes 5 components Higher prevalence of risk factors for medical errors Frequent medical errors of omission Adverse medical event definitions that often fail to

incorporate minority views on what constitutes harm Language barriers cause higher risk of errors and

adverse events Insufficient data collection systems for identifying and

monitoring racial/ethnic disparities

Implications/Take-Away Points Need to identify and study means of reducing

greater minority risk of birth trauma Need to be especially vigilant regarding

prevention, identification, and management of postoperative infectious and non-infectious complications among minorities

Given many adverse patient consequences of language barriers, appropriate language services always should be arranged for LEP patients and families

Implications/Take-Away Points

Evidence suggests that improving patient safety

for minority children could be achieved by Routinely collecting and monitoring parental self-

reported data on race/ethnicity, language, and English proficiency

Enhancing cultural competency of healthcare providers and staff

Providing adequate language services for all LEP patients and their families

Racial/Ethnic Disparities and Patient Safety Thursday, November 15, 2007 12:00 – 1:00 p.m. ET.

Documents

Transcript of Racial/Ethnic Disparities and Patient Safety Thursday, November 15, 2007 12:00 – 1:00 p.m. ET.