English as a second language and outcomes of patients presenting with acute coronary syndromes: results from the CONCORDANCE registry

We thank Gray for his interest in our article.1 We chose the dichotomy of English as a first or second language based on patient self-report; we did not obtain specific data on spoken or written English proficiency, nor did we collect data on the use of professional interpreters throughout the course of our study. We agree that this would help to further inform our conclusions. As clinicians, we endeavour to use the services of professional interpreters to obtain the clinical history, ensure informed consent for procedures, communicate discharge instructions, and to answer any concerns that the patient may have. This often requires engaging a phone interpreter due to limited availability of interpreters for face-to-face interaction in a timely fashion.

Cardiology often requires rapid decision making in unstable patients, where time is of the essence, and it is sometimes necessary to use the services of bilingual staff or family members to convey information to patients, although we accept this is not optimal. We cannot use phone interpreters while patients undergo invasive coronary procedures and, even though we endeavour to have interpreters physically present, there is often insufficient time allocated for this. We therefore use clinical judgement, with respect to the level of English proficiency of the patient and the availability of bilingual staff, to decide whether the interpreter should remain and potentially compromise the need for their services elsewhere. Gray quotes a systematic review2 suggesting that the routine use of a professional interpreter would almost certainly improve patient outcomes. It is notable that this review identified only four inpatient studies (two obstetric, one psychiatric and one oncology ward) and the authors identified no study that demonstrated benefits on hard clinical endpoints such as mortality. There were no studies of acute inpatient cardiology either. In spite of the fact that communication is clearly important, it is conceivable that delaying urgent intervention or administration of relevant medical therapy to patients while waiting for a professional interpreter, as opposed to using immediately available bilingual staff or family members, may also adversely affect patient outcomes. It would be informative to have a randomised comparison of patient comprehension and outcomes of bilingually competent clinical staff compared with professional interpreters.