PDF(Pubmed)
Abstract：
BACKGROUND: Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations.
OBJECTIVE: In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries?
METHODS: On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed.
RESULTS: There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores.
CONCLUSIONS: Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses.
METHODS: Level III, therapeutic study.
OBJECTIVE: In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries?
METHODS: On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed.
RESULTS: There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores.
CONCLUSIONS: Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses.
METHODS: Level III, therapeutic study.
摘要：
背景：美国大约有2500万人的英语水平有限。骨科手术的当前发展，例如，针对捆绑支付模式，扩大术前教育课程或收集患者报告的结果，可能会加剧语言障碍。目前,有限的英语水平与护理过程和结果之间的关联有不同的发现，保证交叉研究综合，以确定关联模式。
目的：在本系统综述中，我们问：英语水平有限与(1)临床护理流程的差异有关，(2)与患者参与相关的护理过程的差异，和（3）在英语国家/地区接受骨科手术的患者的治疗效果较差？
方法：2023年6月9日，从开始到搜索日期对四个数据库进行了系统搜索（PubMed，OvidEmbase,WebofScience,和Scopus）是由医学图书馆员执行的。可能符合条件的文章是观察性研究，该研究检查了接受骨科手术或在骨科手术环境中接受护理的儿科和成年患者的英语水平有限与预定结局类别之间的关系。我们确定了10563条记录,其中，我们在删除重复项后筛选了6966个标题和摘要。我们回顾了56篇全文文章，包括29项同行评审的研究(结果类别：8项用于临床护理过程，10对于与患者参与相关的护理过程，治疗结果为15)，共有362,746名患者或遭遇。我们提取了包括研究特征在内的数据元素，语言暴露的定义，具体结果，和研究结果。使用适用于队列或横断面研究的纽卡斯尔-渥太华量表评估每项研究的质量。大多数研究具有低（48％）或中等（45％）的偏倚风险，但两项横断面研究存在较高的偏倚风险.为了回答我们的问题，我们综合了关联和无差异的发现，按调整后的估计值和未调整的估计值进一步分层，对于每个类别的结果。未进行荟萃分析。
结果：关于有限的英语水平是否与临床护理流程的差异有关，有不同的发现，在接受THA或TKA的患者中，非英语和英语作为首选语言与延迟ACL重建手术以及其他非西班牙语和英语主要语言的神经轴麻与全身麻醉之间的校正相关性最强。英语水平有限也与THA或TKA的住院费用增加有关，但与接受骨折手术的儿科患者的阿片类药物处方无关。对于与患者参与相关的护理过程，根据调整后的估计值,英语水平有限与患者门户使用率下降和患者报告结局指标完成率下降相关.暴露还与其他非西班牙语和英语语言的虚拟访问完成减少以及TKA后术后阿片类药物补充请求减少有关，但与出勤相关的结果没有差异。对于治疗结果，根据调整后的估计，英语水平有限与住院时间增加和非家庭出院相关，但不是医院的回报。关于并发症增加和术后患者报告的结果测量评分较差的关联，存在混合发现。
结论：研究结果表明，需要消除患者参与治疗的语言障碍，包括患者入口使用和患者报告的结果测量完成情况，并确定增加术后医疗保健使用的机制和解决方案。然而,解释受到研究参数异质性的限制，包括语言接触。未来的研究应包括对有限的英语水平和基于可用语言的资源的上下文详细信息的更精确和透明的定义，以支持定量综合。
方法：三级，治疗性研究。
目的：在本系统综述中，我们问：英语水平有限与(1)临床护理流程的差异有关，(2)与患者参与相关的护理过程的差异，和（3）在英语国家/地区接受骨科手术的患者的治疗效果较差？
方法：2023年6月9日，从开始到搜索日期对四个数据库进行了系统搜索（PubMed，OvidEmbase,WebofScience,和Scopus）是由医学图书馆员执行的。可能符合条件的文章是观察性研究，该研究检查了接受骨科手术或在骨科手术环境中接受护理的儿科和成年患者的英语水平有限与预定结局类别之间的关系。我们确定了10563条记录,其中，我们在删除重复项后筛选了6966个标题和摘要。我们回顾了56篇全文文章，包括29项同行评审的研究(结果类别：8项用于临床护理过程，10对于与患者参与相关的护理过程，治疗结果为15)，共有362,746名患者或遭遇。我们提取了包括研究特征在内的数据元素，语言暴露的定义，具体结果，和研究结果。使用适用于队列或横断面研究的纽卡斯尔-渥太华量表评估每项研究的质量。大多数研究具有低（48％）或中等（45％）的偏倚风险，但两项横断面研究存在较高的偏倚风险.为了回答我们的问题，我们综合了关联和无差异的发现，按调整后的估计值和未调整的估计值进一步分层，对于每个类别的结果。未进行荟萃分析。
结果：关于有限的英语水平是否与临床护理流程的差异有关，有不同的发现，在接受THA或TKA的患者中，非英语和英语作为首选语言与延迟ACL重建手术以及其他非西班牙语和英语主要语言的神经轴麻与全身麻醉之间的校正相关性最强。英语水平有限也与THA或TKA的住院费用增加有关，但与接受骨折手术的儿科患者的阿片类药物处方无关。对于与患者参与相关的护理过程，根据调整后的估计值,英语水平有限与患者门户使用率下降和患者报告结局指标完成率下降相关.暴露还与其他非西班牙语和英语语言的虚拟访问完成减少以及TKA后术后阿片类药物补充请求减少有关，但与出勤相关的结果没有差异。对于治疗结果，根据调整后的估计，英语水平有限与住院时间增加和非家庭出院相关，但不是医院的回报。关于并发症增加和术后患者报告的结果测量评分较差的关联，存在混合发现。
结论：研究结果表明，需要消除患者参与治疗的语言障碍，包括患者入口使用和患者报告的结果测量完成情况，并确定增加术后医疗保健使用的机制和解决方案。然而,解释受到研究参数异质性的限制，包括语言接触。未来的研究应包括对有限的英语水平和基于可用语言的资源的上下文详细信息的更精确和透明的定义，以支持定量综合。
方法：三级，治疗性研究。
