Language barrier as social determinant of health: unmasking the disparities in the emergency department evaluation for patients with chest pain at a community hospital

Abstract Background/Introduction Patients with limited English proficiency (LEP) constitute 8.6% of the United States population. They may have lower health literacy related to cardiovascular disease, reluctance to seek care, and communication difficulties in reporting symptoms, posing challenges to care provision. Throughout medical literature, these barriers reportedly lead to increased utilisation of diagnostic testing, hospital admission rate, and length of stay. Purpose Language barrier appears to negatively impact individuals' healthcare experience. The goal of this study is to examine whether disparities exist in the emergency department (ED) evaluation and management of chest pain in LEP patients by comparing their wait time and admission rate to that of English-proficient (EP) counterparts. Methods This retrospective cohort study included adults age 18 or older that presented to our hospital ED with a chief complaint of chest pain from 1/9/2022 to 30/9/2023. We identified all LEP patients during this period and matched a random sample of EP patients in a 1:2 ratio. We treated each encounter as an independent subject and eliminated those that left prior to disposition. Our primary outcomes were time from arrival to provider evaluation, and admission rate. Covariates were sex, age, race, acuity level, arrival mode, and insurance status to adjust for characteristic difference between cohorts. Descriptive comparisons between cohorts and bivariate outcomes were conducted using independent samples t-tests for continuous variables and chi-squared tests for categorical ones. Multivariable linear and logistic regression models were used to compute adjusted mean wait time for provider and adjusted odds of admission, respectively. All analyses were done on SAS 9.4. Results Our study sample included 690 encounters, with 239 LEP and 451 EP patients. The two cohorts were similar in sex, age, and acuity level, but there were significant disparities in insurance status, arrival mode, and race. A higher proportion of EP patients were admitted to the hospital or observational unit than LEP patients (45.0% vs. 28.0%, respectively, P<0.001). After multivariable adjustment, LEP patients were half as likely to be admitted compared to EP patients (adjusted odds ratio, 0.51 [95% CI, 0.35-0.74], P<0.001). LEP patients waited longer for provider evaluation from the point of ED arrival, though this was not statistically significant when adjusting for acuity and arrival mode (19.6 minutes, [95% CI, 5.9-45.1], P=0.132). Conclusions Whilst we did not observe a significant difference in wait time for provider between LEP and EP patients, LEP patients were less likely to be admitted when presenting with chest pain at the ED. One possibility is that language barrier may limit a patient’s ability to convey cardiac versus non-cardiac chest pain, adversely influencing downstream management and outcomes. To address this, further large-scale investigation is needed.