Abstract
Background
Recent studies have described the use of telehealth for pediatric surgical care during the COVID-19 pandemic. We aimed to evaluate equity in telehealth use by comparing rates of utilization and satisfaction with pediatric surgical telemedicine among Hispanic patients.
Methods
We conducted a retrospective cohort study of patients seen by a surgical subspecialty provider in the outpatient setting at a quaternary pediatric hospital between April 1 and June 30, 2020. Patients evaluated in the same three-month period in 2019 were analyzed as a historic control. Differences in Family Experience Survey (FES) responses based on race and ethnicity and preferred language of care were assessed using univariable and multivariable generalized linear modeling.
Results
The pandemic cohort included fewer patients of Hispanic ethnicity and fewer Spanish-speakers. After controlling for visit type, comparison of Spanish-speaking and English-speaking patients revealed that Spanish-speaking families had significantly lower scores for FES items that evaluated healthcare provider explaining (IRR 0.74, 95% CI: 0.61–0.90), listening (IRR 0.76, 95% CI: 0.63–0.92), and time spent with the family (IRR 0.73, 95% CI: 0.60–0.89). There were no differences in FES responses based on insurance status or degree of medical complexity.
Conclusions
Telehealth services were less commonly used among Hispanic and Spanish-speaking patients. Language may differentially affect family satisfaction with healthcare and telehealth solutions. Strategies to mitigate these inequities are needed and may include strengthening interpreter services and providing language-concordant care.
Level of evidence
Level IV.
Keywords: Pediatric surgery, Telemedicine, Health equity
Abbreviations: ADI, Area deprivation index; APP, Advanced practice provider; CDC, Centers for Disease Control and Prevention; COVID-19, Coronavirus disease 2019; FES, Family Experience Survey; IRR, Incidence Rate Ratio; NRC, National Research Corporation; PMCA, Pediatric Medical Comorbidity Algorithm; SARS CoV-2, Severe acute respiratory syndrome coronavirus 2; US, United States
1. Introduction
The World Health Organization officially recognized COVID-19, caused by SARS CoV-2 virus infection, as a global pandemic in March 2020 [1]. In the absence of targeted medical therapies or vaccination, early pandemic management strategies focused on preventing viral transmission [1]. The Centers for Disease Control and Prevention (CDC) called on hospitals and outpatient clinics to limit all non-essential patient care activities, and patients were encouraged to follow stay-at-home orders [2]. The Centers for Medicare and Medicaid Services supported these new CDC guidelines by waiving telemedicine restrictions and allowing virtual consultations to be compensated at rates equivalent to office visits [3]. Consequently, hospitals and clinics shifted from providing in-person appointments to telemedicine [1,4,5].
Pediatric surgical subspecialties were included in the rapid expansion of telehealth services. A survey of caregivers who participated in at least one pediatric surgery telemedicine appointment during the COVID-19 pandemic found that 79% thought telemedicine was equivalent to, if not better, than an in-person visit [6]. A second survey study reported that the majority of families received excellent pediatric surgical care (76%) and would choose telemedicine again in the future (57%). This study sample, however, was overwhelmingly non-Hispanic white (82.8%) and insured (91.8%) [7]. Quality telemedicine requires reliable Internet connection and a smart phone, tablet, or computer that can run video-conferencing software. Lower rates of digital access have been reported in historically minoritized racial and ethnic communities [4,8,9].
We aimed to expand the existing body of literature by investigating rates of utilization and satisfaction with telehealth among Hispanic patients. Telehealth was rolled out at our institution in March 2020 to support COVID-19 social distancing. The Hispanic patient population represents the largest racial and ethnic minority group at our institution. Additionally, data from the US Department of Health and Human Services showed that Hispanic patients were less likely than any other racial or ethnic group to access health services during the first year of the pandemic [10].
We compared results from the Family Experience Survey (FES) for pediatric patients who received surgical subspecialty care in person or through telehealth visits. We analyzed whether there were differences in patient satisfaction. We hypothesized that FES scores would be lower for telehealth visits than for in-person visits and that FES scores would be lower among Hispanic patients.
2. Methods
This was a retrospective cohort study conducted at a large quaternary pediatric hospital system. The study included FES responses from parents and caregivers of children who were seen by a surgical subspecialty physician or advanced practice provider (APP) between April 1 and June 30, 2020. FES responses from the same three-month period in 2019 were analyzed as a historical control. The response rate for the FES was 22%, which was on par with other pediatric surgery centers who used the survey. The Seattle Children's Hospital Institutional Review Board approved this research.
Patients were given the option of an in-person, telemedicine, or telephone visit when considered appropriate by their healthcare provider. Telemedicine visits were provided with video-conferencing software built into the hospital system's electronic health record. Patients connected to video-conferencing software for telemedicine visits through their patient portal using a smartphone, tablet, or computer. Instructions for patient portal set-up were provided verbally at the time of appointment scheduling. If patients were unable to connect to video-conferencing software, they were offered a telephone visit. Interpreters were made available for patients whose primary language was other than English for both in-person and telehealth visits.
After each encounter, all parents and caregivers were invited to complete the FES. Based on our institution's existing practice, if the patient's primary language was English, a link to the FES was emailed for the survey to be completed online immediately following the clinic encounter. If no online response was recorded within 48-h, then the parent or caregiver was invited to complete the survey using an automated telephone recording system. If the patient's primary language was Spanish, the family was contacted via telephone directly to complete the survey using a touch-tone system. Families were eligible to complete the FES once every 180 days.
The FES is a quality and patient satisfaction survey that is administered by NRC Health, a healthcare consumer data company. The FES includes 21 questions that aim to evaluate families’ satisfaction with the care they receive from physicians and APPs (Table 1 ). These questions are adapted from the Consumer Assessment of Healthcare Providers and Systems Survey and were individualized for the study institution [11]. The questions are written at the sixth grade reading level and have been professionally translated by NRC Health.
Table 1.
Family Experience Survey items and response format.
| Response Format in a 0–10 Numeric Scale | |
|---|---|
| Study Abbreviation | FES Question |
| Provider Rating | Using any number from 0 to 10, where 0 is the worst and 10 is the best, what number would you use to rate this provider? |
| Office Recommendation |
How likely would you be to recommend this provider's office to your family and friends? |
| Response Format in a 4-Point Likert Scale | |
| Study Abbreviation | |
| Explaining | During your most recent visit, did this provider explain things about your health in a way that was easy to understand? |
| Listening | During your most recent visit, did this provider listen carefully to you? |
| Questions | Did you talk with this provider about any questions or concerns you had about your child's health? |
| Understanding | Did this provider give you easy-to-understand information about these health questions or concerns? |
| Medical History Knowledge | Did this provider seem to know the important information about your medical history? |
| Respect | Did this provider show respect for what you had to say? |
| Time | Did this provider spend enough time with you? |
Generalized linear mixed effect models were used to analyze population differences between the pandemic cohort and the historical cohort with random participant intercepts to account for repeated measures. We evaluated patient race and ethnicity, preferred language of care, insurance status, and medical complexity. Medical complexity was determined by the Pediatric Medical Comorbidity Algorithm (PMCA), which stratifies children according to the complexity and chronicity of their health conditions (complex chronic, non-complex chronic, non-chronic, and no PMCA designation) [12].
Univariable and multivariable generalized linear models were used to assess factors associated with top box FES scores among the pandemic cohort. A top box score is defined as a 9 or 10 on the 0–10 numeric scale or a 4 on the 4-point Likert scale, and it is the recommended scoring system according to NRC Health and the Centers for Medicare and Medicaid Services [13,14]. Generalized linear mixed-effects modeling was used to evaluate the differences in FES score based on ethnicity, preferred language, insurance status, and PMCA. Telemedicine and telephone appointments were combined into a “telehealth” variable for ease of analysis. Results were adjusted using the Benjamin-Hochberg method for multiple comparisons. A p value of 0.05 served as the cut-off for statistical significance. All statistical analysis was performed in R [15].
3. Results
1262 patients were enrolled in the pandemic cohort and 2072 in the historical cohort (Table 2 ). The median patient age was 4.82 years (IQR 0.96–9.30) in the pandemic cohort and 5.39 years (IQR 1.40, 10.41) in the historical cohort (p = 0.001). More than half the patients were male in both groups (54.6%, 55.8%, p = 0.501). There was a significantly higher proportion of non-Hispanic white patients in the pandemic cohort (55.2%) compared to the historic cohort (49.5%, p = 0.018). The remaining patient population in the pandemic cohort identified as Hispanic (15.6%), Black or African American (3.9%), Asian (7.1%), or Other (11.0%). The overwhelming majority of patients in both cohorts spoke English, although the proportion in the pandemic cohort (94.0%) was significantly greater than in the historic cohort (90.8%, p = 0.001). The increase in the percentage of English speakers represented in the pandemic cohort was associated with a corresponding decrease in Spanish speakers from 9.2% to 6.0%. Most patients reported having commercial insurance in both cohorts (59.3%, 56.6%, p = 0.493). Relatively few patients had complex chronic medical conditions as defined by the PMCA, although the proportion of patients with a complex chronic condition (15.5%) was significantly higher in the pandemic cohort (p = 0.009).
Table 2.
Patient demographics for the 2019 Historic Cohort and 2020 Pandemic Cohort.
| 2019 Historic Cohort n (%) | 2020 Pandemic Cohort n (%) | p value | |
|---|---|---|---|
| Overall | 2072 | 1262 | |
| Patient gender | |||
| Female | 916 (44.2) | 573 (45.4) | 0.501 |
| Male | 1156 (55.8) | 689 (54.6) | |
| Agea | 5.39 [1.40, 10.41] | 4.82 [0.96, 9.30] | 0.001 |
| Race and Ethnicity | |||
| Non-Hispanic white | 1026 (49.5) | 697 (55.2) | 0.018 |
| Hispanic | 380 (18.3 | 197 (15.6) | |
| Black or African American | 107 (5.2) | 49 (3.9) | |
| Asian | 178 (8.6) | 89 (7.1) | |
| Other | 239 (11.5) | 139 (11.0) | |
| Language | |||
| English | 1828 (90.8) | 1145 (94.0) | 0.001 |
| Spanish | 185 (9.2) | 73 (6.0) | |
| Insurance | |||
| Commercial | 1004 (56.6) | 684 (59.3) | 0.493 |
| Public | 770 (43.4) | 469 (40.7) | |
| Medical Complexity (PMCA) | |||
| Complex chronic | 265 (12.8) | 196 (15.5) | 0.009 |
| Noncomplex chronic | 614 (29.6) | 357 (28.3) | |
| Nonchronic | 294 (14.2) | 239 (19.0) | |
| Not categorized | 899 (43.4) | 469 (37.2) | |
Median [IQR].
There was a dramatic increase in telemedicine and telephone encounters during the pandemic compared to the same time period in the previous year (Table 3 ). In 2020, more than half of outpatient pediatric surgical subspecialty visits were conducted either via telemedicine (41.6%) or telephone (13.5%), compared to only 0.2% in the year prior. The majority of these telehealth visits were in Orthopedics (39.4%) or Otolaryngology (20.0%); however, there was no significant difference in the surgical specialty break-down between pandemic and historical cohorts (Table 3).
Table 3.
Clinic characteristics for the 2019 Historic Cohort and 2020 Pandemic Cohort.
| 2019 Historic Cohort |
2020 Pandemic Cohort |
p value | |
|---|---|---|---|
| n (%) | n (%) | ||
| Visit type | |||
| In-person | 1784 (99.8) | 522 (44.9) | <0.001 |
| Telemedicine | 3 (0.2) | 484 (41.6) | |
| Telephone | 0 (0.0) | 157 (13.5) | |
| Surgical subspecialty | |||
| Cardiac | 7 (0.3) | 3 (0.2) | 0.082 |
| General and thoraci | 173 (8.1) | 96 (7.2) | |
| Neurosurgery | 52 (2.4) | 43 (3.2) | |
| Ophthalmology | 223 (10.5) | 143 (10.7) | |
| Orthopedics | 886 (41.6) | 526 (39.4) | |
| Otolaryngology | 395 (18.5) | 267 (20.0) | |
| Plastics | 20 (0.9) | 27 (2.0) | |
| Transplant | 15 (0.7) | 4 (0.3) | |
| Urology | 360 (16.9) | 225 (16.9) | |
There were no differences in the proportion of top box responses for any of the nine FES questions evaluated by language, ethnicity, insurance status, or PMCA classification between the pandemic and historical cohorts (Table 4 ). Similarly, univariable generalized linear modeling for patients in the pandemic cohort who participated in a telehealth appointment showed no significant differences in FES responses between vulnerable populations and the referent groups (Table 5 ). Multivariable generalized linear modeling for 2020 patients again failed to find differences in FES responses between vulnerable populations and the referent groups. Furthermore, multivariable modeling showed that there were no differences in FES responses for those patients who participated in telehealth visits during the pandemic compared to those who saw a surgical subspecialty provider in-person after controlling for preferred language, ethnicity, insurance status, and medical complexity (Table 6 ). Non-Hispanic white race, rather than Hispanic ethnicity, was used as the covariate in multivariable modeling to reduce multicollinearity given the correlation between Spanish speaking and Hispanic ethnicity.
Table 4.
Proportion of top box FES responses among pediatric surgical patients in the 2019 historic cohort and 2020 pandemic cohort, irrespective of visit type.
| 2019 Historic Cohort |
2020 Pandemic Cohort |
|||||||
|---|---|---|---|---|---|---|---|---|
| Questions |
Spanish Speaking |
Hispanic Ethnicity |
Public Insurance |
Complex Chronic Medical Condition |
Spanish Speaking |
Hispanic Ethnicity |
Public Insurance |
Complex Chronic Medical Condition |
| n (%) | 194 (9.2) | 397 (18.3) | 940 (43.6) | 291 (13.4) | 78 (6.0) | 218 (16.1) | 540 (40.3) | 222 (16.4) |
| Explaining | 104 (55.9) | 232 (64.1) | 604 (69.3) | 198 (76.7) | 16 (44.4) | 74 (71.8) | 191 (72.1) | 56 (84.8) |
| Listening | 115 (63.5) | 261 (74.1) | 656 (77.4) | 215 (84.6) | 23 (63.9) | 83 (81.4) | 207 (79.0) | 58 (87.9) |
| Questions | 111 (62.7) | 240 (70.4) | 597 (72.5) | 193 (76.6) | 20 (55.6) | 70 (70.0) | 184 (72.2) | 48 (73.8) |
| Understanding | 116 (65.9) | 251 (74.9) | 630 (77.2) | 203 (80.9) | 18 (50.0) | 78 (78.8) | 198 (78.6) | 56 (86.2) |
| Medical History Knowledge | 97 (55.4) | 224 (67.5) | 543 (67.0) | 193 (76.9) | 13 (38.2) | 61 (62.9) | 176 (70.7) | 52 (80.0) |
| Respect | 121 (69.9) | 270 (81.8) | 661 (81.9) | 218 (86.9) | 20 (62.5) | 80 (84.2) | 202 (81.8) | 56 (86.2) |
| Time | 103 (60.2) | 235 (71.9) | 596 (74.4) | 205 (82.7) | 19 (59.4) | 78 (82.1) | 193 (78.5) | 53 (81.5) |
| Provider Rating | 142 (87.7) | 275 (87.3) | 642 (83.4) | 194 (79.2) | 58 (87.9) | 161 (87.5) | 401 (86.1) | 170 (86.7) |
| Office Recommendation | 138 (92.0) | 275 (92.3) | 642 (88.1) | 200 (84.4) | 56 (87.5) | 158 (88.3) | 393 (87.1) | 164 (87.7) |
Table 5.
Univariable generalized linear modeling of top box FES responses among pediatric surgical patients who participated in a telehealth visit in 2020.
| Questions | Spanish Speakinga |
Hispanic Ethnicityb |
Public Insurancec |
Complex Chronic Medical Conditiond |
|---|---|---|---|---|
| IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | |
| Explaining | 1.16 (0.35–2.83) | 1.09 (0.52–2.06) | 0.97 (0.58–1.62) | 1.10 (0.54–2.04) |
| Listening | 1.08 (0.33–2.63) | 1.01 (0.48–1.90) | 0.97 (0.59–1.59) | 1.02 (0.51–1.88) |
| Questions | 1.33 (0.40–3.25) | 1.25 (0.59–2.38) | 1.12 (0.65–1.93) | 0.99 (0.45–1.93) |
| Understanding | 0.84 (0.21–2.27) | 1.05 (0.50–1.98) | 1.1 (0.67–1.83) | 1.06 (0.53–1.96) |
| Medical History Knowledge | 0.94 (0.23–2.56) | 0.92 (0.40–1.84) | 1.13 (0.66–1.94) | 1.08 (0.51–2.06) |
| Respect | 1.03 (0.31–2.50) | 1.05 (0.52–1.93) | 1.03 (0.64–1.68) | 0.95 (0.47–1.74) |
| Time | 0.92 (0.22–2.50) | 1.03 (0.47–2.01) | 0.94 (0.55–1.59) | 0.81 (0.35–1.62) |
| Provider Rating | 1.03 (0.72–1.44) | 1.00 (0.79–1.26) | 0.99 (0.83–1.18) | 1.03 (0.84–1.26) |
| Office Recommendation | 1.08 (0.75–1.50) | 1.04 (0.82–1.31) | 1.04 (0.87–1.23) | 1.01 (0.82–1.24) |
Spanish speaking compared to English speaking (referent).
Hispanic compared to non-Hispanic (referent).
Public insurance compared to commercial insurance (referent).
Complex chronic medical condition compared to no chronic medical condition (referent).
Table 6.
Multivariable generalized linear modeling of top box FES responses among pediatric surgical patients in 2020, irrespective of visit type.
| Questions | Spanish Speakinga |
Non-Hispanic Whiteb |
Public Insurancec |
Complex Chronic Medical Conditiond |
Telehealthe |
|---|---|---|---|---|---|
| IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | IRR (95% CI) | |
| Explaining | 0.57 (0.34–0.97) | 1.09 (0.90–1.32) | 0.96 (0.79–1.17) | 1.06 (0.80–1.40) | 1.08 (0.83–1.42) |
| Listening | 0.76 (0.49–1.19) | 1.04 (0.86–1.26) | 0.96 (0.80–1.16) | 1.02 (0.77–1.34) | 1.09 (0.84–1.42) |
| Questions | 0.72 (0.44–1.15) | 1.01 (0.82–1.23) | 1.02 (0.83–1.25) | 0.97 (0.72–1.31) | 1.02 (0.76–1.36) |
| Understanding | 0.57 (0.34–0.93) | 0.97 (0.81–1.18) | 1.00 (0.82–1.21) | 1.01 (0.76–1.34) | 1.04 (0.80–1.37) |
| Medical History Knowledge | 0.50 (0.28–0.88) | 1.05 (0.85–1.28) | 1.04 (0.85–1.27) | 1.07 (0.80–1.44) | 1.06 (0.79–1.41) |
| Respect | 0.73 (0.45–1.16) | 1.04 (0.86–1.25) | 0.97 (0.80–1.18) | 0.97 (0.74–1.29) | 1.13 (0.87–1.46) |
| Time | 0.72 (0.44–1.17) | 1.00 (0.83–1.22) | 0.96 (0.79–1.16) | 0.98 (0.73–1.30) | 0.97 (0.73–1.29) |
| Provider Rating | 1.02 (0.77–1.36) | 1.02 (0.89–1.17) | 1.02 (0.89–1.17) | 1.01 (0.85–1.19) | 1.03 (0.90–1.17) |
| Office Recommendation | 1.01 (0.76–1.36) | 1.03 (0.90–1.18) | 1.02 (0.89–1.18) | 1.02 (0.86–1.21) | 0.98 (0.86–1.12) |
Spanish speaking compared to English speaking (referent).
Non-Hispanic White compared to Others (referent).
Public insurance compared to commercial insurance (referent).
Complex chronic medical condition compared to no chronic medical condition (referent).
Telehealth compared to in-person (referent).
Table 7 shows that there were no differences between FES responses between those patients who participated in telehealth visits during the pandemic and patients who participated in in-person appointments during the historic control. When controlling for visit type, however, Spanish-speaking families had significantly lower scores for FES items that evaluated healthcare provider explaining (IRR 0.74, 95% CI: 0.61–0.90), listening (IRR 0.76, 95% CI: 0.63–0.92), and time spent with the family in consultation (IRR 0.73, 95% CI: 0.60–0.89) compared to English-speaking patients. There were also trends toward lower scores for questions, understanding, medical history knowledge, and respect, although these did not meet criteria for statistical significance after adjustment using the Benjamin-Hochberg method for multiple comparisons. Interestingly, Spanish-speaking families did not report lower global ratings of their healthcare experience. These families were still likely to rate their providers highly and to recommend the office to other patients (Fig. 1 ).
Table 7.
Multivariable generalized linear mixed modeling of top box FES responses comparing Spanish-speaking and English-speaking pediatric surgical patients, controlling for visit type.
| Questions | Spanish speakinga |
Telehealthb |
|---|---|---|
| IRR (95% CI) | IRR (95% CI) | |
| Explaining | 0.74 (0.61–0.90)∗ | 1.16 (0.89–1.50) |
| Listening | 0.76 (0.63–0.92)∗ | 1.12 (0.87–1.44) |
| Questions | 0.83 (0.69–1.01) | 1.02 (0.78–1.34) |
| Understanding | 0.79 (0.66–0.95) | 1.08 (0.83–1.39) |
| Medical History Knowledge | 0.78 (0.63–0.95) | 1.13 (0.86–1.48) |
| Respect | 0.8 (0.67–0.97) | 1.12 (0.88–1.44) |
| Time | 0.73 (0.60–0.89)∗ | 0.99 (0.76–1.30) |
| Provider Rating | 1.06 (0.91–1.24) | 1.06 (0.96–1.17) |
| Office Recommendation | 1.07 (0.91–1.25) | 0.99 (0.89–1.09) |
∗p < 0.05, p-values are adjusted using the Benjamin−Hochberg method for multiple comparisons.
Spanish speaking compared to English speaking (referent).
Telehealth compared to in-person (referent).
Fig. 1.
Forest plot showing the incidence rate ratio (IRR) and 95% confidence interval (CI) of top box responses for each FES item, comparing Spanish-speaking and English-speaking patients while controlling for visit type.
3. Discussion
This study compared satisfaction with telehealth among pediatric patients who received surgical subspecialty care during the COVID-19 pandemic to a historical control. We performed statistical analysis to determine whether there were differences in visit type and patient satisfaction. We found that the proportions of racial and ethnic minority and Spanish-speaking patients were lower in the pandemic cohort compared to the historical control. Ethnicity, insurance status, and degree of medical complexity did not appear to negatively impact family satisfaction with telemedicine for pediatric surgical subspecialty care. When compared to English-speaking families, however, Spanish-speaking families were less likely to highly rate their provider on survey items pertaining to explanation of the patient's health, listening to the family's concerns, and time spent with the family during the consultation.
These findings are important given that Latinx is the fastest growing demographic group in the United States [16,17]. In fact, Hispanics account for nearly 55% of US population growth [18]. Many Latinx families report speaking Spanish at home, and 8.5% have limited English proficiency [16]. Numerous studies have demonstrated that language barriers adversely impact both access to medical care and the quality of care received [[18], [19], [20], [21], [22]]. The consequences of this inequity include, but are not limited to, longer hospital stays, medical errors, and lower patient satisfaction [22].
Data from the National Survey of Early Childhood Health found that Hispanic children were significantly less likely to be in “excellent” or “very good health.” Furthermore, Hispanic parents most often reported that healthcare providers never or only sometimes understood their child's needs [18]. Some authors have proposed language-concordant care may improve health equity for Latinx patients, particularly those with limited English proficiency [21]. Health care provider's Spanish language fluency has been highly correlated with their ability to understand a patient's health-related cultural beliefs, which may differ from those of the patients who belong to the dominant culture [17,23]. Additionally, provider-patient language concordance facilitates meaningful interactions between patients and their medical team and allows patients to actively participate in their care [18,21].
Previous research has shown that language concordance is important to patients with limited English proficiency. Eskes et al., for example, found that 83.7% of patients valued having a health care provider who spoke fluent Spanish [17]. Similarly, Dunlap, et al. determined that families with Spanish-speaking medical teams had a higher level of healthcare satisfaction than those with either an English-speaking provider or an interpreter [18]. In particular, language-concordant care has been shown to correlate positively with patient-reported satisfaction scores for how members of the medical team listen, answer questions, explain medical procedures, and discuss follow-up [18,23,24].
While Spanish-speaking families in our study responded less positively on specific measurements of satisfaction with their health care providers, their composite provider and office scores were comparable to their English-speaking counterparts. Other studies have similarly found discrepancies between specific and global satisfaction scores among Latinx patients, with global satisfaction scores being higher. For example, Wandell, et al., found that, while Spanish speaking families were 1.7 times more likely than English speaking families (95% CI: 1.24–2.22) to give their healthcare provider a top box rating, they were less likely to rate their provider highly for individual aspects of care including explaining, listening, and knowledge of the patient's medical history [16]. Another study found that although Spanish and English language speakers reported similar overall satisfaction with the healthcare they received, Spanish speakers were less likely than English speakers to report understanding the medical information relayed to them (OR 0.21, 95% CI: 0.1–0.78) and less comfortable than English speakers in asking questions of their healthcare providers (OR 0.32, 95% CI: 0.2–0.5) [25]. These response patterns may reflect the inability of survey instruments to adequately assess family satisfaction in this patient population, lower expectations for quality of care, or a cultural tendency to defer to medical authority [16,25,26].
There are several limitations to this study. Our institution's average FES response rate was 22%, which was on par with other pediatric surgery centers who used the survey. The relatively small sample size resulting from low response may have contributed to our inability to detect differences on multivariable generalized linear modeling. Our results, which come from a single-center study, may not be generalizable to other centers. Additionally, our decision to focus on Hispanic and Spanish speaking patients prohibits our results from being used to draw conclusions about the pandemic experiences of other historically minoritized ethnic and linguistic groups. It should also be noted that the FES was not designed to assess language and cultural discordance between patients' families and their health-care providers. A separate survey tool would need to be designed and administered to better evaluate family satisfaction within the Spanish-speaking Latinx patient population.
Finally, although it is the standard of care at our institution to offer interpreter services, the paradigm shift toward telemedicine has presented new challenges to ensuring adequate language resources. Interpreter Services at our institution estimated that an in-person interpreter was used for approximately 75% of outpatient visits with patients whose primary language was Spanish pre-pandemic. Pandemic data show that the percent of outpatient encounters with in-person interpretation for Spanish speaking families has dropped to approximately 71.5% with a corresponding increase in use of video or telephone interpreters. The use of a professional interpreter has been shown to improve patient-provider communication by enhancing understanding and to result in higher patient satisfaction scores [24,27]. However, some studies suggest that in-person interpreters may be preferable to virtual interpretation services with regard to cultural competency and patient comfort [28,29].
4. Conclusion
This study adds to the emerging literature on the use of telemedicine for pediatric surgical subspecialty care. We found fewer patients of Hispanic ethnicity and fewer Spanish-speakers received care at our institution's outpatient surgical subspecialty clinics during the COVID-19 pandemic. Families who received care expressed similar levels of satisfaction when receiving care through telemedicine or telephone visits compared with traditional in-person visits, irrespective of minority ethnicity, insurance status, or degree of medical complexity. Spanish-speaking families, however, reported lower satisfaction with providers' explanation of the patient's health, listening to the family's concerns, and time spent with the family during the consultation. Future directions include developing metrics that more accurately assess satisfaction among the Spanish-speaking Latinx patient population, improving the telehealth experience for Hispanic families, strengthening interpreter services at our institution, and piloting language-concordant care.
Previous communication
None.
Financial support statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
We have no competing interests to declare.
Acknowledgements
This work was made possible by the Surgical Equity Workgroup to Underscore Population Health (SEW-UP) in the Department of Surgery at Seattle Children's Hospital and the University of Washington.
References
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