Predictors of Language Service Availability in U.S. Hospitals

Document Type: Original Article

Authors

1 San Diego State University, San Diego, CA, USA

2 Suffolk University, Boston, MA, USA

3 University of Wisconsin-Madison, Madison, WI, USA

Abstract

Background
Hispanics comprise 17% of the total U.S. population, surpassing African-Americans as the largest minority group. Linguistically, almost 60 million people speak a language other than English. This language diversity can create barriers and additional burden and risk when seeking health services. Patients with Limited English Proficiency (LEP) for example, have been shown to experience a disproportionate risk of poor health outcomes, making the provision of Language Services (LS) in healthcare facilities critical. Research on the determinants of LS adoption has focused more on overall cultural competence and internal managerial decision-making than on measuring LS adoption as a process outcome influenced by contextual or external factors. The current investigation examines the relationship between state policy, service area factors, and hospital characteristics on hospital LS adoption.
 

Methods
We employ a cross-sectional analysis of survey data from a national sample of hospitals in the American Hospital Association (AHA) database for 2011 (N= 4876) to analyze hospital characteristics and outcomes, augmented with additional population data from the American Community Survey (ACS) to estimate language diversity in the hospital service area. Additional data from the National Health Law Program (NHeLP) facilitated the state level Medicaid reimbursement factor.
 

Results
Only 64%of hospitals offered LS. Hospitals that adopted LS were more likely to be not-for-profit, in areas with higher than average language diversity, larger, and urban. Hospitals in above average language diverse counties had more than 2-fold greater odds of adopting LS than less language diverse areas [Adjusted Odds Ratio (AOR): 2.26, P< 0.01]. Further, hospitals with a strategic orientation toward diversity had nearly 2-fold greater odds of adopting LS (AOR: 1.90, P< 0.001).
 

Conclusion
Our findings support the importance of structural and contextual factors as they relate to healthcare delivery. Healthcare organizations must address the needs of the population they serve and align their efforts internally. Current financial incentives do not appear to influence adoption of LS, nor do Medicaid reimbursement funds, thus suggesting that further alignment of incentives. Organizational and system level factors have a place in disparities research and warrant further analysis; additional spatial methods could enhance our understanding of population factors critical to system-level health services research.

Keywords

Main Subjects


 

  1. Shin H, Kominski R. Language Use in the United States: 2007. Washington, DC: U.S. Census Bureau; 2010.
  2. Pandya C, Batalova J, McHugh M. Limited English Proficient Individuals in the United States: Number, Share, Growth, and Linguistic Diversity. Washington, DC: Migration Policy Institute; 2011.
  3. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care 2007; 19: 60-7.  doi: 10.1093/intqhc/mzl069
  4. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007; 42: 727-54.  doi: 10.1111/j.1475-6773.2006.00629.x
  5. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J. Culturally competent healthcare systems. A systematic review. Am J Prev Med 2003; 24: 68-79.  
  6. Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med 2012; 27: 1294-9.  doi: 10.1007/s11606-012-2041-5
  7. Cheng EM, Chen A, Cunningham W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med 2007; 22: 283-8.  doi: 10.1007/s11606-007-0346-6
  8. Ku L, Flores G. Pay now or pay later: providing interpreter services in health care. Health Aff (Millwood) 2005; 24: 435-44.  doi: 10.1377/hlthaff.24.2.435
  9. Goode TD, Dunne MC, Bronheim SM. The Evidence Base for Cultural and Linguistic Competency in Health Care. Georgetown University: National Center for Cultural Competence, Center for Child and Human Development; 2006. Report No. 962.
  10. Wilson-Stronks A, Lee K, Cordero C, Kopp A, Galvez E. One Size does not Fit All: Meeting the Healthcare Needs of Diverse Populations. Oakbrook, IL: The Joint Commission; 2008.
  11. Federal Register. Executive Order 13166 - Improving Access to Services for Persons with Limited English Proficiency. Washington, DC: Federal Register; 2000. p. 6.
  12. Federal Register. Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. Washington, DC: Coordination and Review Section, Civil Rights Division; 2002.
  13. Diamond LC, Luft HS, Chung S, Jacobs EA. "Does This Doctor Speak My Language?" Improving the Characterization of Physician Non-English Language Skills. Health Serv Res 2011.  doi: 10.1111/j.1475-6773.2011.01338.x
  14. Diamond LC, Wilson-Stronks A, Jacobs EA. Do hospitals measure up to the national culturally and linguistically appropriate services standards? Med Care 2010; 48: 1080-7.  doi: 10.1097/MLR.0b013e3181f380bc
  15. Grubbs V, Chen AH, Bindman AB, Vittinghoff E, Fernandez A. Effect of awareness of language law on language access in the health care setting. J Gen Intern Med 2006; 21: 683-8. doi: 10.1111/j.1525-1497.2006.00492.x
  16. Ortega A. . . . And health care for all: immigrants in the shadow of the promise of universal health care. Am J Law Med 2009; 35: 185-204. 
  17. Youdelman MK. The medical tongue: U.S. laws and policies on language access. Health Aff (Millwood) 2008; 27: 424-33.  doi: 10.1377/hlthaff.27.2.424
  18. Wilson-Stronks A, Mutha S. From the perspective of CEOs: what motivates hospitals to embrace cultural competence? J Health Manag 2010; 55: 339-51. 
  19. Guerrero EG. Managerial capacity and adoption of culturally competent practices in outpatient substance abuse treatment organizations. Journal of Substance Abuse Treatment 2010; 39: 329-39.  doi: 10.1016/j.jsat.2010.07.004
  20. DiMaggio P, Powell W. The Iron Cage Revisited: Institutional Isomorphism and collective rationality in organizational fields. American Sociologica Review 1983; 48: 147-60. 
  21. Meyer J, Rowan B. Institutionalized Organizations: Formal Structure as Myth and Ceremony. American Journal of Sociology 1977; 83: 340-63. 
  22. Donabedian A. The quality of care. JAMA 1988; 260: 1743-8. 
  23. DiMaggio PJ, Powell WW. The Iron Cage Revisited: Institutional Isomorphism and Collective Rationality in Organizational Fields. American Sociological Review 1983; 48: 13. 
  24. Suchman MC. Managing Legitimacy - Strategic and Institutional Approaches. Academy of Management Review 1995; 20: 571-610.  doi: 10.2307/258788
  25. Powell WW, DiMaggio P. The New institutionalism in organizational analysis. Chicago: University of Chicago Press; 1991.
  26. Chen JT, Coull BA, Waterman PD, Schwartz J, Krieger N. Methodologic implications of social inequalities for analyzing health disparities in large spatiotemporal data sets: an example using breast cancer incidence data (Northern and Southern California, 1988--2002). Stat Med 2008; 27: 3957-83.  doi: 10.1002/sim.3263
  27. Scott WR, Davis GF. Organizations and organizing : rational, natural, and open system perspectives. 1st ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2007.
  28. Luft HR, Garnick D, Maerki S, McPhee S. The Role of Specialized Clinical Services in Competition among Hospitals. Inquiry 1986; 23: 11. 
  29. Greenwood R. The SAGE handbook of organizational institutionalism. Los Angeles, London: SAGE; 2008.
  30. Pearson M. Disparities in health expenditures across OECD countries: Why does the United States spend so much more than other countries?. 2009. Available from: http://www.oecd.org/unitedstates/43800977.pdf
  31. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med 2007; 22: 362-7.  doi: 10.1007/s11606-007-0366-2
  32. Norton EC, Staiger DO. How hospital ownership affects access to care for the uninsured. The Rand journal of economics 1994; 25: 171-85. 
  33. Wilson-Stronks A, Galvez E. Hospitals, Language and Culture: A Snapshot of the Nation: Exploring Cultural and Linguistic Services in the Nation's Hospitals. Joint Commission; 2007.
  34. Weech-Maldonado R, Al-Amin M, Nishimi RY, Salam F. Enhancing the cultural competency of health-care organizations. Adv Health Care Manag 2011; 10: 43-67. 
  35. Weech-Maldonado R, Fongwa MN, Gutierrez P, Hays RD. Language and regional differences in evaluations of Medicare managed care by Hispanics. Health Serv Res 2008; 43: 552-68.  doi: 10.1111/j.1475-6773.2007.00796.x
  36. Wennberg DE. Variation in the delivery of health care: The stakes are high. Annals of Internal Medicine 1998; 128: 866-8. 
  37. Betancourt JR, Tan-McGrory A. Creating a safe, high-quality healthcare system for all: meeting the needs of limited English proficient populations; Comment on "Patient safety and healthcare quality: the case for language access". Int J Health Policy Manag 2014; 2: 91-4.  doi: 10.15171/ijhpm.2014.21
  38. Andrulis DP, Jahnke LR, Siddiqui NJ, Cooper MR. Implementing Cultural and Linguistic Requirements in Health Insurance Exchanges. Texas Health Institute; 2013. Available from: http://www.texashealthinstitute.org/health-care-reform.html
  39. Alliance of Community Health Plans Foundation. Making the Business Case for Culturally and Linguistically Appropriate Services in Health Care: Case Studies from the Field. Merck Foundation; 2007.
  40. Weech-Maldonado R, Elliott MN, Pradhan R, Schiller C, Dreachslin J, Hays RD. Moving towards culturally competent health systems: organizational and market factors. Soc Sci Med 2012; 75: 815-22.  doi: 10.1016/j.socscimed.2012.03.053