Impact of Language Barriers on Patient Satisfaction
in an Emergency Department
Olveen Carrasquillo, MD, MPH, E. John Orav, PhD, Troyen A. Brennan, MD, JD, MPH,
Helen R. Burstin, MD, MPH
OBJECTWE: To examine patient satisfaction and willingness to
return to an emergency department (ED) among non-English
speakers.
DESIGN: Cross-sectional survey and follow-up interviews 10
days after ED visit.
SETTING: Five urban teaching hospital EDs in the Northeast-
em United States.
PATIENTS: We surveyed 2,333 patients who presented to the
ED with one of six chief complaints.
MEASUREMENTS AND MAIN RESULTS:Patient satisfaction.
willingness to return to the same ED if emergency care was
needed, and patient-reported problems with care were mea-
sured. Three hundred fifty-four (15%) of the patients reported
English was not their primary language. Using an overall mea-
sure of patient satisfaction, only 52% of non-English-speaking
patients were satisfied as compared with 71% of English
speakers ( p . .01). Among non-English speakers, 14% said
they would not return to the same ED if they had another
problem requiring emergency care as compared with 9.5% of
English speakers ( p .05). In multivariate analysis adjusting
for hospital site, age, gender, race/ethnicity, education, in-
come, chief complaint, urgency, insurance status, Medicaid
status, ED as the patient's principal source of care, and pres-
ence of a regular provider of care, non-English speakers were
significantly less likely to be satisfied (odds ratio [OR]0.59:
95% confidence interval [CI] 0.39, 0.90) and significantly less
willing to return to the same ED (OR 0.57: 95% Ci 0.34,
0.95). Non-English speakers also were significantly more
likely to report overall problems with care (OR 1.70: 95% CI
1.05, 2.74). communication (OR 1.71: 95% CI 1.18. 2.47),
and testing (OR 1.77: 95% CI 1.19, 2.64).
CONCLUSIONS: Non-English speakers were less satisfied with
their care in the ED, less willing to return to the same ED if
they had a problem they felt required emergency care, and re-
ported more problems with emergency care. Strategies to im-
prove satisfaction among this group of patients may include
appropriate use of professional interpreters and increasing the
language concordance between patients and providers.
Recc>iivd,/rorrt the Dcl~crrtrnerily / -Medicirw. Cambridge Hospi-
I d , Carrtbrid{gc.. Mass. (OC): Dicisiori of Gerieral Medicine, De-
partmerit of Afediciiie.higham arid Women's Hospital. Boston.
Xlnss. (TAB. HRB): arid Harmrd School of Public Health. Bos-
ion. Mass. ( M O . TAHI.
P r c w r i i d in pan nf ihr, urinunl session qf the Society ofGen-
c m l Infcnial !Medicine. Wasliirigtori.D.C.. May 3. 1996.
Address corresporidcrice and r q x i r i t requests to Dr. Burstin:
Ilepartrnerir oJ- Qualify Maiirigmxmt Seruices. Brigham and
Il'ornfw's tfospitnl. 75 Francis Sr.. Boston. MA 021 15.
82
KEY WORDS: patient satisfaction: communication barriers:
language: Hispanic Americans.
J GEN INTERN MED 1999:14:82-87.
I n 1990 14 million people living in the United States
had limited proficiency in English. I Despite growing
recognition of language barriers in m e d i ~ i n e , little
~ - ~ data
exist about patient satisfaction in non-English speakers.
A study in Arizona showed the language of interview was
related to satisfaction among Hispanic children, but not
aniong adultss Another study in California showed that
language concordance and interpreter use greatly affected
patients' understanding of their disease, but did not re-
port patient satisfaction.6 In addition, it has been sug-
gested that language barriers may help explain the lower
levels of satisfaction among Asians and Pacific Islanders
in the Medical Outcomes Study.7 In contrast, a study in
Boston reported that English-speaking patients were less
likely to be satisfied with the courtesy and respect of office
staff a s compared with Spanish-speaking patients.8
The emergency department (ED) is of particular im-
portance because it serves many patients who lack health
insurance or access to primary care providers. Studies
from California estimate that about 5OVo of patients seen
in the ED faced barriers to primary care,y or lacked a
non-ED regular source of care.'" A s a result the ED is a
major provider of care to poor and uninsured patients, a
large portion of whom have limited English proficiency.
For example, in Los Angeles Latino patients were over
twice as likely as other patients to use the ED as a regular
source of care." In addition, despite a perceived need by
patients. interpreters are often not used in the ED.4 and
when used. usually lack formal training in this skill.
We hypothesize that non-English-speaking patients
who are treated in the ED are less likely to be satisfied
with the care they receive. To evaluate this hypothesis we
examined data collected in the Harvard Emergency Depart-
ment Quality Study, a quality improvement effort between
five EDs in urban teaching hospitals in the Northeastern
United States. One of the critical measures of quality in
this study was patient assessment of quality of care. To de-
termine if language bamers play a role in the delivery of
quality care. the study included questions about the pri-
mary language of patients.
METH0DS
The study was camed out at the EDs of five nonprofit
private hospitals associated with Harvard Medical School:
JGIM Volume 14, February 1999
~-
Beth Israel Hospital, Brigham and Womens Hospital,
Massachusetts General Hospital, Mount Auburn Hospital,
and the New England Deaconess Hospital. The study was
approved by the human subjects committee at each insti-
tution. The study was conducted during a 1-month period
in each hospital from February to May 1995. Patients who
presented to the adult ED with a chief complaint of ab-
dominal pain, chest pain, asthma, hand laceration, head
trauma, or vaginal bleeding were eligible. These com-
plaints were chosen because of their prevalence in the ED
and their potential for medical injury. For logistical rea-
sons, patients were enrolled between the hours of 10 AM
and 12 midnight, but every third day patients were en-
rolled all 24 hours. Patients were approached by research
assistants who obtained informed consent for the study.
Patients were not eligible for the questionnaire portion of
the study if they were incapacitated by medical illness, in-
toxicated, or confused (as determined by the ED staff),
were nonpregnant minors, left without being seen, were
previously surveyed, or did not have one of the six chief
complaints.
On-site questionnaires were self-administered (in En-
glish or Spanish) or administered by interviewers who were
bilingual in English and Spanish. If needed, a proxy such
as a relative was used to obtain the information. The on-
site questionnaire included questions about sociodemo-
graphic characteristics including gender, race/ethnicity,
education, household income, insurance, Medicaid cover-
age, whether the patients had a regular provider of care,
and whether the patients consider the ED as their primary
source of care.
A follow-up telephone interview occurred approxi-
mately 10 days after the ED visit. The follow-up interview
assessed satisfaction with ED care, self-reported problems
with process of care, compliance with follow-up instruc-
tions, and self-reported health status a t the time of follow-
up interview. At this interview the patients primary lan-
guage was assessed by asking patients the following ques-
tion: Is English your first language? If necessary, these
interviews were conducted in Spanish.
Patient satisfaction in the follow-up interview was as-
sessed by asking patients to rate overall care, courtesy and
respect from the staff, completeness of care received, ex-
planation of what was being done, waiting times, and dis-
charge instructions. All questions were rated on a
5-category Likert scale, with responses ranging from 1
(poor) to 5 (excellent). The Cronbachs a for these satisfac-
tion measures, an estimate of the internal consistency reli-
ability,12was 0.88 for the English version and 0.85 for the
Spanish version. Patients were also asked if they would re-
turn to the same ED if they had another problem that re-
quired emergency care.
Patient-reported process-of-care measures were ob-
tained by adapting questions from the Picker-Common-
wealth Study13 for the ED. We grouped dichotomous re-
sponses to these questions into subscales regarding
communication (six questions), follow-up (four questions),
83
medication use (four questions), and diagnostic testing (two
questions). Reported communication problems included
discharge kom the ED without sufficient explanation of the
possible causes of the problem or without the discharge in-
structions being understood. Follow-up problems included
lack of information about the danger signs of worsening ill-
ness or under what circumstances to return to the ED.
Medication problems included insufficient instruction re-
garding how to take advised medications or insufficient in-
formation about potential side effects. Testing problems in-
cluded inadequate explanation of the reasons for testing or
of test results. Internal validation for the patient-reported
problems instrument revealed a Cronbachs a of 0.62 for
the English version and 0.71 for the Spanish version.
Medical records were reviewed to verify the chief com-
plaint and to obtain a complaint-specific measure of pa-
tient urgency on presentation to the ED, based on previ-
ously published triage criteria.I4 This urgency scale has
four levels ranging from evaluation of a stable medical
condition to the need for immediate evaluation of a life-
threatening condition.
Statistical Analysis
Patients were considered satisfied if they rated their
satisfaction as excellent (5)or very good (4). A total satis-
faction score was obtained by considering a s satisfied any
patient who had a n average satisfaction score of 4 or
more in the six satisfaction questions. Report of a patient
problem on any item in a subscale was scored as having a
problem in that subscale. Any patient report of a problem
in any subscale was included in the total problem score.
We used x2 tests to compare dichotomous variables.
Logistic regression was used to analyze independent corre-
lates of patient satisfaction, willingness to return, and
patient-reported problems. The multivariate models in-
cluded age (as a continuous variable), gender, race/ethnic-
ity (non-Hispanic white, black, Latino, or other), education
(less than high school, completed high school, or greater),
income (less than $15,000, $15,000-$49,999, or greater
than $50,000), chief complaint, urgency, whether the in-
terviews were conducted with the patient or a proxy (e.g.,
relative who may have also served as a translator), insur-
ance status, Medicaid status, ED at which the patient was
seen, if the patient had a regular provider of care and if the
patient considered the ED as their principal source of care.
To determine if satisfaction varied among the non-English-
speaking subgroups, we performed separate logistic regres-
sion analyses comparing Latino non-English-speaking pa-
tients and non-Latino non-English-speaking patients to
English speakers. All analyses were performed using SAS
(SAS Institute, Cary, N.C.) and all p values are two sided.
RESULTS
During the study period 3,455 eligible patients pre-
sented to the ED. Of these, 2,899 (84%)agreed to complete
84 Carrasquillo et al.. Language t3amers and Patient SatisJaction JCIM
~ ~ ~ ~~~~~~~ ~~ -~~

the baseline questionnaires. There were no significant dif-
ferences in age, gender, insurance status. urgency, chief
complaint. admission status. or hospital identity among
patients eligible for baseline questionnaires and those who
completed the questionnaire. Follow-up interviews were
conducted on 2,333 (80%)of these patients. Patients who
could not be reached at follow-up were more likely to be
male and uninsured. There were no significant differences
in age. urgency, chief complaint. admission status. or hos-
pital between patients who did and those who did not com-
plete follow-up questionnaires.
Of the 2.333 patients who had follow-up interviews,
352 (15%~) reported that English was not their first lan-
guage. The percentage of non-English-speaking patients at
each hospital ranged from l0Yn to 24% ( p < ,001 across
groups). Among patients who reported English was not
their primal?. language. 50% were Latino. 25% were white
(mostly Russian and Eastern European). 1 loio were black
(mostly Haitian Creole). and 15% were Asian or other. Non-
English speakers were significantly more likely to be Latino
or Asian/other and less likely to be white or black. Non-
English speakers were significantly more likely to be
younger, have lower household incomes, have lower educa-
tional attainment. have a lower urgency rating (less-urgent
problem), lark a primary doctor. consider the ED a s their
primary source of care, have no health insurance, and be
covered by Medicaid (Table 1). Among non-English speak-
ers, 20'46 of non-Latinos needed a proxy to complete the
questionnaire a s compared myth 8% of Latinos ( p < ,001).
In univariate analvsis non-English-speaking patients
were significantly less likely to be satisfied on each of the
satisfaction subscales (Fig. 1). Using the total satisfaction
score. only 52n/i, of non-English-speaking patients were
satisfied as compared with 71% of English speakers ( p <
,001). Among non-English speakers 14% said they would
not return to the same ED if thev had another problem re-
quiring emergency care a s compared with 9.5Vn of English
speakers (p -'.05).
Other factors that were individually associated with
higher satisfaction included older age, higher household
income. higher educational status, higher severity rating
(sicker patients), and patients who presented with chest
pain or hand lacerations. Those with lower satisfaction in-
cluded black and Latino patients, Medicaid recipients, and
patients who lacked a regular provider of care. Patients
who considered the ED as their site of regular medical
care were also less likely to be satisfied, 58% versus 64%
( p < .05). Among the individual hospitals the percentage
of patients who reported being satisfied ranged from 56%
to 81% ( p < .01 across groups).
Multivariate models reiterated that non-English
speakers were less likely to be satisfied (Table 2). Among
the satisfaction subscales non-English speakers were less
likely to be satisfied with the courtesy and respect received
and the explanation of discharge instructions. In addition,
non-English speakers were less willing to return to the
same ED if they had another problem requiring emergency
care (Table 2). Multivariate analysis limited to Latino non-
English speakers or to non-Latino non-English speakers
also showed each group was less likely to be satisfied (odds
ratio [OR] 0.54, 95% confidence interval [CI] 0.34, 0.88:
and OR 0.57, 95%CI 0.35, 0.94, respectively) as compared
with English speakers. Other factors that were significantly
associated with satisfaction in multivariate models in-
cluded younger age ( p < .05, as a continuous variable) and
black race (OR 0.67: 95% CI 0.47, 0.95: p < .05).
We then examined patient-reported problems with
care. In univariate analysis non-English speakers were
more likely to report problems with communication ( p <
.001), diagnostic testing ( p 1 .Ol), medication use ( p <
.01). and follow-up ( p < .06; Fig. 2). Patients who reported
problems with care were more likely to be Latino, younger,
have a lower severity rating (less acute problem), and have
a college education. Patients who presented with chest
pain or asthma were less likely to report problems with
care.

Table 1. Characteristics of English and Non-English Speakers

English Speakers Non-EnglishSpeakers

Characteristic ( n = 1,979) ( n = 354) p Value*
Mean age z S D . years 47 3 20 41 -t 18 1.001
Male. % 42 44 NS
White, %I 78 24 <.001
Black. " h 16 11 .02
I,atino, % 3 50 <.001
Asian / other, "6 3 15 1.001
Education 'c 12 years. '% 12 33 .<.001
Inc,oine <S15.000. "41 38 62 <.001
Uninsured. % 30 40 <.001
Covered by Medicaid. 15 24 <.001
Srverity rating 5 2 (lessacute). ' M I 40 52 1.001
l a d no primary doctor. ('41 21 34 <.001
Emergency department is source of primary care. Yo 12 23 <.001

*.\IS indicates riot sigriificcmr.

JGIM Volume 14, February 1999 85

hglish Speakers .English Speakers

100%
loox T hn-mglish Speakers
85%
mNon-EnplSh Speakem

80%
80%
59% 66%
60%

5
r 40%
39%

20% 28%

0%
OYerall Courtesy and Conpkteness Explanationof Waning Tm Dscharge
Respect ofcare MatWas hstructions 0%
Done Total. Communlcahon Follow-up

FIGURE 1. Patient satisfaction subscales among English and

FIGURE 2. Patient-reported problems among English and non-
non-Englishspeakers. All differenceswere significant at p < ,001,
English speakers: p < .05.

In multivariate analysis non-English speakers re- speakers to report problems with testing (OR 2.00, 95% CI
mained more likely to report problems with testing (OR 1.77; 1.28, 3.11) and communication (OR 1.49; 95% CI 0.99, 2.78).
95% CI 1.19, 2.64), communication (OR 1.71; 95% CI 1.18,
2.47) and overall reported problems (OR 1.70; 95% CI 1.05,
DISCUSSION
2.74). In separate multivariate analysis Latino non-English
speakers tended to report more problems with testing (OR What many patients resent today is their inability to
1.55; 95% CI 0.98, 2.46) and communication (OR 1.47; communicate with physicians in a meaningful manner . . .
95% CI 0.96, 2.23), and reported more overall problems (OR to have a practical effect on the patient the clinician must
2.36; 95% CI 1.30, 4.29), than English speakers. Non- have the facility to communicate with him.15Although still
Latino non-English speakers were more likely than English very applicable, these words were reported in 1970 from an
opening lecture to third-year medical students. Thus, it
should not be surprising that we found non-English-
speaking patients were less satisfied with the care they re-
Table 2. Multivariate Analysis of Satisfaction, Willingness to ceived in the ED and less willing to return. In fact, we
Return, and Problems with Care by Language* found only half of the non-English-speaking patients were
satisfied with the care they received in the ED. Further-
Odds Ratio+
Variable (95% CI) D Value+ more, even when adjusted for other possible confounders,
non-English speakers were still considerably less satisfied
Total satisfaction scores 0.58 (0.38, 0.88) <.01
and were half as likely as English speakers to return to the
Satisfaction subscales
Overall care 0.57 (0.39, 0.81) <.01 same ED if they had another problem requiring emergency
Courtesy and respect 0.66 (0.45, 0.96) C.05 care. Accordingly, we also found non-English speakers re-
Completeness of care 0.76 (0.53, 1.09) NS ported more problems with care including discussion of
Explanation of what was done 0.77 (0.54, 1.09) NS causes of a medical condition, understanding discharge in-
Waiting time 0.78 (0.54, 1.12) NS structions, and explanation of reasons for diagnostic test-
Discharge instructions 0.59 (0.40, 0.87) 1.01 ing and their results. Consistent with prior studies,16 we
Willingness to return if had also found that patients who were young or black were also
another problem requiring less likely to be satisfied.
emergency care 0.55 (0.33, 0.92) <.05
Although few studies have examined satisfaction among
Total problems with care11 1.70 (1.05, 2.74) <.05
Problem subscalesP non-English speakers, investigators have shown the impact
Communication 1.71 (1.18, 2.47) 1.01 of language barriers on processes of care or other outcomes.
Follow-up 1.27 (0.88, 1.841 NS One study in New York City reported that Spanish-speaking
Medication use 1.11 (0.76, 1.62) NS asthmatic patients whose physician spoke Spanish had im-
Diagnostic testing 1.77 (1.19. 2.64) <.01 proved compliance and less ED use than those who did not
have a Spanish-speaking doctor.17Another study among ED
* Non-English speaking as compared with English speakers.
Controlling for hospital site, age, gender, race/ethnicity, educa- patients with long bone fractures found that Spanish-speak-
tion, income, chief complaint, urgency, insurance status, Medicaid ing patients were less likely to receive anesthesia.* In San
status, emergency department as the patients principal source of Francisco, Perez-Stable and colleagues found that after ad-
care, a n d presence of a regular provider of care. justing for confounding variables, non-English-speaking pa-
+NSindicates not signijkant.
tients with diabetes and hypertension reported better well-
Mean of satisfaction subscales with excellent a n d very good con-
sidered satisfied. being and functioning in 10 of 14 health status measures
IIAny reported problem in one of 16 questions. when their physician spoke their native 1ang~age.l~ Others
Any reported problem in the questions in that scale. have also shown that language concordance is associated
86 Carrasquillo et al.. Language Barriers and Patient Satisfaction
~- ~
with more questions being asked and increased understand-
ing by Spanish-speaking patients.2o
These studies a s \yell a s our own suggest that institu-
tions serving large populations with limited English lan-
guage proficiency give increased emphasis to reducing
these language barriers. Some have advocated strategies
such as recruiting pro\iders who are linguistically (and
ideally cullurally) competent in that language.2.19 2 1 or
sponsoring English as a Second Language classes for pa-
tients.' However. in many institutions. the most pragmatic
solution has been to rely on interpreters. Unfortunately, all
too often. rather than using professional interpreters,
translation IS proiided by anyone who is bilingual and
happens to be convenient to the scene such as family mem-
bers or ancillary staff.21-':3These ad hoc translators often
commit typical errors such a s omission, addition. conden-
sation. substitution. or role exchange (interpreter assumes
the role of interviewer or intcnriewee).2:3,24
In addition. aside
from violating a patient's right to privacy.") such interpret-
ers usually only translate and cannot place the message
into the appropriatr social and cultural context a s a pro-
fessional inlerpreter is trained to do. Others have sug-
gested the use of interpreters at remote sites connected to
the patient and clinician remote headsets as occurs in
international conferences but again important roles of
the interpreters such as assessment of gestures and facial
expressions as well as elaboration of cultural expressions
of an illness would not be possible.
Some limitations of our study should be considered in
interpreting our findings. Although we dichotomized lan-
guage proficiency. most would agree it is a more continu-
011s concepl. By inrlnding all patients that reported En-
glish was not their first language among the non-English
speakers. we utilized the most inclusive definition of lan-
guage proficiency and were still able to observe differences
in satisfaction. Second, similar satisfaction uith care may
be rated differently on a Likert scale by different cultural
groups owing to their inherent conceptualization of how
the scale should be anchored. For example, other investi-
gators examining need for medical care have suggested
that the reason Latinos have a lower self-rating of health
despite having the low& perceived need for medical care is
because they may consider a certain level of health a s
"good" while other cultural groups may consider the same
level as "very good or excellent".2"However. we were able to
deiiionstratr similar results using a dichotomous measure
lor satisfaction. namely. willingness to return.
Also. although our models included education and income,
our study did not assess functional health literacy. which
inay be an important barrier to care in the ED.27 Finally.
our study questionnaires and follow-up interviews were
conducted only in Spanish or English. We have attempted
to control for these differences by including race and use of
a surrogate in the multivariate models. In addition. sub-
group analysis among Latino non-English speakers or
non-latino non-English speakers yielded similar results.
In conclusion. we found that non-English speakers
J GlM
were less satisfied with their care in the ED and less willing
to return to the same ED. In light of the growing recogni-
tion that patient satisfaction is an important indicator of
quality of care.28 addressing the satisfaction of non-
English-speaking patients becomes imperative. In fact, the
National Committee on Quality Assurance in its most re-
cent Health Employer Data and Information Set 3.0 has
made it clear that addressing the language needs of its
beneficiaries is just as important as other components of
quality.29Thus, given the growing diversity of the U S . pop-
ulation, efforts are needed to ensure patients receive lin-
guistically and culturally competent care. Further research
will be needed to determine if more appropriate use of pro-
fessional interpreters or increasing the language concor-
dance between patients and providers improves satisfac-
tion among non-English speakers.
Or. Olveen Carrasquillo was supported b y a General Medicine
Research Fellowship, HRSA grant 2028 PE500 78-04.
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Letter to the Editor or a
short creative writing piece
for possible publication in the Journal,
please e-mail us at

jgim@mail.med.upenn.edu