The Association between Limited English Proficiency and Sepsis Mortality
BACKGROUND: Limited English proficiency (LEP) has been implicated in poor health outcomes. Sepsis is a frequently fatal syndrome that is commonly encountered in hospital medicine. The impact of LEP on sepsis mortality is not currently known.
OBJECTIVE: To determine the association between LEP and sepsis mortality. DESIGN: Retrospective cohort study.
SETTING: 800-bed, tertiary care, academic medical center.
PATIENTS: Electronic health record data were obtained for adults admitted to the hospital with sepsis between June 1, 2012 and December 31, 2016.
MEASUREMENTS: The primary predictor was LEP. Patients were defined as having LEP if their self-reported primary language was anything other than English and interpreter services were required during hospitalization. The primary outcome was inpatient mortality. Mortality was compared across races stratified by LEP using chi-squared tests of significance. Bivariable and multivariable logistic regressions were performed to investigate the association between mortality, race, and LEP, adjusting for baseline characteristics, comorbidities, and illness severity.
RESULTS: Among 8,974 patients with sepsis, we found that 1 in 5 had LEP, 62% of whom were Asian. LEP was highly associated with death across all races except those identifying as Black and Latino. LEP was associated with a 31% increased odds of mortality after adjusting for illness severity, comorbidities, and other baseline characteristics, including race (OR 1.31, 95% CI 1.06-1.63, P = .02).
CONCLUSIONS: In a single-center study of patients hospitalized with sepsis, LEP was associated with mortality across nearly all races. This is a novel finding that will require further exploration into the causal nature of this association.
© 2019 Society of Hospital Medicine
Sepsis is defined as a life-threatening organ dysfunction that occurs in response to systemic infection.1,2 It is frequently fatal, common in hospital medicine, and a leading contributor to critical illness, morbidity, and healthcare expenditures.2-5 While sepsis care and outcomes have improved in the past decade,6,7 inpatient mortality remains high.8
A number of studies have sought to determine whether race plays a role in sepsis mortality. While Black patients with sepsis have frequently been identified as having the highest rates of death,9-14 similar observations have been made for most non-White races/ethnicities.13-15 Studies have also demonstrated higher rates of hospital-acquired infections among Asian and Latino patients.16
There are several possible explanations for why racial minorities experience disparate outcomes in sepsis, including access to care, comorbidities, implicit biases, and biological or environmental factors,17-20 as well as characteristics of hospitals most likely to care for racial minorities.13,15,21 One explanation that has not been explored is that racial disparities in sepsis are mediated by language. Limited English proficiency (LEP) has previously been associated with increased rates of adverse hospital events,22 longer length of stay,23 and greater likelihood of readmission.24 LEP has also been shown to represent a significant barrier to accessing healthcare and preventive screening.25 The role of LEP in sepsis mortality, however, has yet to be examined.
The diverse patient population at the University of California, San Francisco (UCSF) provides a unique opportunity to build upon existing literature by further exploring racial differences in sepsis, specifically by investigating the role of LEP. The objective of this study was to determine the association between LEP and inpatient mortality among adults hospitalized with sepsis.
METHODS
Setting
The study was conducted at the University of California, San Francisco, California (UCSF), an 800-bed tertiary care, academic medical center. It was approved by the UCSF Institutional Review Board with waiver of informed consent. UCSF cares for a population of patients who are racially and linguistically diverse, with high proportions of patients of East Asian descent and with LEP. According to recent United States census estimates, more than half of San Francisco County residents identify as non-White (35% Asians, 15% Hispanic/Latino, 6% Black), and 44% report speaking a language other than English at home.26
Study Population and Data Collection
The UCSF Medical Center uses the electronic health record (EHR) Epic (Epic 2017, Epic Systems Corporation, Verona, Wisconsin). We obtained computerized EHR data from Clarity, the relational database that stores Epic’s inpatient data in thousands of tables. We identified all patients ≥18 years of age presenting to the emergency department (ED) between June 1, 2012 and December 31, 2016 with suspected serious infection, defined as having blood cultures ordered within 72 hours of ED presentation (N = 25,441). Patients who did not receive at least two doses of intravenous (IV) antibiotics within 48 hours were excluded, as they were unlikely to have serious infections.
