Communication and healthcare complexity in people with little or no English: the Communication Complexity Score

To investigate the level of healthcare complexity of patients with limited English and the probability of use of professional interpreters, at a tertiary hospital in a multicultural area of Sydney, Australia.

A multilingual telephone survey was matched with medical record reviews to assess modes of communication in a sample of 258 patients with limited English from nine language groups. The Model of Interpreter Usage and Complexity was used to explain the association between clinical complexity and interpreter usage. To measure clinical complexity, a summative rating scale, the Communication Complexity Score (CCS) was constructed comprising eight weighted scores related to admission status, urgency of admission, triage category, medical emergencies/events, HDU/ICU admission, numbers of medications, invasiveness of procedures, and diagnosis. Robust Multiple Logistic Regression was used for modelling the likelihood of interpreter usage with different levels of complexity.

Of the 205 patients (79%) who spoke little or no English, 31% reported usage of professional interpreters. There was a positive association between CCS and usage of interpreters. Patients with high and moderate CCSs were significantly more likely to have used interpreters (OR=32.9, 95% CI 12.4-87.1 and OR=10.8, 95% CI 3.2-36.5, respectively). The CCS was found to have good psychometric properties and to be internally consistent (Cronbach's Alpha 0.84). The model was found to have good predictive power (Area under the Receiver Operating Characteristic curve 0.90).

While most patients (69%) had no interpreter, patients with high or moderate CCSs were more likely to have an interpreter, demonstrating a robust relationship between these two variables. Poor usage of interpreters in the Emergency Department was observed. Family and friends had a significant role in communication. These findings have important safety, policy, and practice implications for patients with limited English proficiency.