Outcomes of Children With Medical Complexities Based on Language Spoken

07/18/2024

This Concise Critical Appraisal reviews a recent study exploring the outcomes of children with medical complexities who speak a language other than English.

Children with medical complexities (CMC) are an increasing population in pediatric intensive care units (PICUs). They use a disproportionate share of critical care resources and account for longer hospital lengths of stay (LOS), higher costs, and higher mortality rates.¹ The families of these patients can also have mental, socioeconomic, and familial stressors related to their children’s care.

While speaking a language other than English (LOE) is common in the United States, it can present significant barriers to pediatric patients and their families. Studies have demonstrated a significant increase in adverse events in pediatric patients with non-English-speaking families compared with patients whose families express comfort with English.^2,3 Pediatric patients of non-primary English speakers have also been shown to have longer LOS and to be more dependent on technology.⁴

Taken together, being CMC and speaking an LOE can exacerbate the difficulties each population faces alone. Pilarz et al examined the association between CMC patients/families and speaking an LOE.⁵ Then they sought to determine whether being CMC and speaking an LOE were associated with worse outcomes. Outcome measures included initial illness severity, PICU and hospital LOS, organ dysfunction-free days, and ventilator-free days.

The authors conducted a single-site, retrospective observational cohort study among children admitted to a PICU in a U.S. quarternary children’s hospital over a five-year span. Evaluation of patients with more than one encounter included a random person-level effect to establish any within-person correlations. As in many centers, patients requiring chronic invasive ventilation at this center were admitted only to the PICU. The authors used the electronic medical record (EMR) to identify patient subjects.

Preferred language was determined by first examining the EMR and then performing a manual chart review for an LOE. Languages were then categorized as English, Spanish, or language other than English or Spanish (LOES). Medical complexity was determined using the Complex Chronic Condition Classification System, with a score of 3 or more organ systems being categorized as complex (along with any technology dependence).

Out of 10,011 total encounters, 6802 unique patients met inclusion criteria. Of these encounters, 51.9% were CMC and 14.3% spoke an LOE. Of the LOE encounters, 82.8% spoke Spanish, 19.8% spoke Arabic, 14.6% spoke Chinese, 8.5% spoke Urdu, and 8.5% spoke Burmese. Among all encounters, LOE speakers were associated with increased odds of being CMC compared with patients proficient in English in both univariate and multivariable analyses. When looking at unique patients, only Spanish speakers were associated with being CMC. LOES speakers had lower organ dysfunction-free days, higher PICU LOS, and higher hospital LOS (although LOES speakers who were not CMC also had higher hospital LOS). CMC who were primary Spanish speakers did not demonstrate any of the secondary outcomes.

Pilarz et al determined that CMC were associated with families who speak an LOE, which was a novel finding. While only the children of families speaking an LOES demonstrated a longer LOS (both in CMC and in non-CMC), they acknowledge that this may be related to the small sample size. They also acknowledge the role population-level differences may play in their findings, since this was single-site study. Additionally, levels of language preference may be difficult to assess in families whose members have different proficiency levels. However, the increased prevalence of CMC in families speaking an LOE remains an issue, especially in medical centers with insufficient language interpretation (often not in person) and knowledge of various cultural norms. This study serves as a reminder of the vulnerability patients and families face when these populations overlap.

References

Simon TD, Berry J, Feudtner C, et al. Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010 Oct;126(4):647-655.
Khan A, Yin HS, Brach C, et al; Patient and Family Centered I-PASS Health Literacy Subcommittee. Association between parent comfort with English and adverse events among hospitalized children. JAMA Pediatr. 2020 Dec 1;174(12):e203215.
Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005 Sep;20(9):800-806.
Pilarz M, Rodriguez G, Jackson K, Rodriguez VA. The impact of non-English language preference on pediatric hospital outcomes. Hosp Pediatr. 2023 Mar 1;13(3):244-249.
Pilarz MS, Bleed E, Rodriguez VA, et al. Medical complexity, language use, and outcomes in the pediatric ICU. Pediatrics. 2024 Jun 1;153(6):e2023063359.

Knowledge Area:

Tags:

Outcomes of Children With Medical Complexities Based on Language Spoken

Recent Blog Posts