Background: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected certain racial and ethnic minority groups, many of whom may not speak english as a primary language. Patients with Limited English proficiency (LEP) have previously been shown to have worse outcomes in the hospital, including higher odds of mortality from sepsis. We investigated the association between LEP and clinical outcomes in patients hospitalized with COVID-19.
Methods: We conducted a retrospective cohort study of all adults hospitalized with COVID-19 respiratory disease between February 2020 and August 2021 at an urban 800-bed tertiary care academic hospital system that cares for a large population of LEP patients. Demographic and clinical data were obtained from the electronic health record. The primary predictor was LEP, which was defined as either a self-reported primary language other than English and/or the use of interpreter services while hospitalized. The primary outcome was in-hospital mortality. Secondary outcomes included inpatient length of stay, intensive care unit length of stay, and need for mechanical ventilation. Demographics and clinical characteristics were stratified by LEP using two-sample t-tests or chi-squared tests of significance. Bivariable and multivariable regression models were utilized to determine the association between LEP and primary and secondary outcomes adjusting for demographics, comorbidities, initial severity of illness and race.
Results: The sample included 633 adult patients who were admitted for COVID-19 respiratory disease during the enrollment period. 34 percent (N=220) were found to be LEP, of whom 46% (N=101) were LatinX. Patients with LEP were older (P< 0.001), more likely to be non-white (P< 0.001), more likely to live in the local metropolitan area (P=0.001) and noted to have more comorbidities (Elixhauser, P=0.001) (Table 1). In bivariate analysis LEP was associated with increased in-hospital mortality (13% vs. 8%, P=0.038), longer length of stay (9.3 days vs. 7.1 days, P=0.001), increased number of ICU days (P=0.004) and increased need for mechanical ventilation (22% vs. 11%, P< 0.001) and vasopressors (30% vs. 17%, P< 0.001) (Table 1). In multivariable analysis, after adjustment for demographics, comorbidities, and initial severity of illness, differences in in-hospital mortality and secondary outcomes were no longer statistically significant. (Table 2)
Conclusions: In conclusion, we found that patients with LEP had a more severe course of disease (higher level of care on admission, higher length of stay and number of ICU days, and increased need for intubation) and higher mortality. However, these differences were explained by other underlying differences in demographics, comorbidities and initial severity of illness and LEP was not found to be an independent marker of disparities in care for this sample. COVID-19 represents a unique population in whom social distance care practices required for all affected patients may have attenuated some of the disparities in clinical outcomes observed between LEP and non LEP patients in other diseases such as sepsis.
