Association of telemedicine use with disparities in cancer distress screening for patients with limited English proficiency.
Authors: Roy Mohana , Fardeen Touran , Cabot Anna , Bruzzone Bianca , Savadamuthu Vikashini , Kasprick Devin , Cheung Lily , Teske Erin , Ramchandran Kavitha 
Published: September 2021

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Background: Distress has a significant impact on the quality of life for patients with cancer, however, implementation of such screening is variable. There is limited data in this area for patients who have limited English proficiency (LEP). Given data suggesting worsening disparities in medical care with telemedicine use, we evaluated the completion of distress screening and interpreter use for LEP patients with telemedicine. Methods: We analyzed assigned (complete and incomplete) questionnaires from 10/2019-3/2021 at Stanford Cancer Center (n = 181,105). We defined LEP as a patient electronic health record (EHR) demographic listing either a non-English preferred language or a request for an interpreter. We defined telemedicine as any video or phone visit. Data was analyzed with Fisher's test for differences. Given limitations in EHR data, we conducted a validation subset chart review for LEP patients in Thoracic and Gastrointestinal (GI) oncology which have the two highest % of LEP patients (n = 177 patients). The subset list was obtained for the above timeframe from the interpreter services group. We analyzed EHR notes from visit day for written mention of professional vs family interpreter use. Results: Overall, 14% of our cohort had LEP, highest prevalence in the Thoracic (21%) and GI groups (16%), with a total of 48 languages represented (Spanish, Mandarin & Vietnamese as the 3 most common). There was a significant difference in the English and Non-English groups in overall completion rates of the screening questionnaire (62% in English population vs 49% for LEP, p < 0.001). Completion rates for telemedicine vs. in person visits were overall higher for both English (78.9% vs. 55%, p < 0.001) and LEP (65.1% vs. 43.7%, p < 0.001) groups respectively. The overall screening completion rate for all visits was 57%, with a 62% completion rate with telemedicine and 51% completion with in-person visits (p = 0.2). In the LEP validation subset, there were 18 languages represented with the similar distribution as the larger cohort. Of all clinical notes reviewed, 48.8% included written mention of professional interpreter use, while 25.5% noted interpretation by a family member. There was no difference in professional interpreter use between visit types (̃50%), but with higher rate of family interpretation with telemedicine (35%) vs with in person visits (21%) (p = 0.04). Conclusions: Patients who have some level of limited English proficiency complete distress screening questionnaires less frequently compared to English speaking patients, which highlights the need to improve access to distress screening and supportive care. However, we found similar completion rates with in person vs telemedicine visits, with a signal for increased use of family members as interpreter with telemedicine. This warrants further analysis of the family role and patient understanding during these virtual visits.