Barriers to guideline concordant cancer care for patients with limited english proficiency: A mixed methods study.

Abstract

e13842 Background: Approximately 25 million people in the United States have limited English proficiency (LEP), posing challenges in communication and disparities in healthcare access, particularly for cancer care. However, the quality and guideline concordance of cancer care for patients with LEP remains understudied, particularly in cancers that have high incidence in migrant populations, such as colon and gastric cancer. The aims of this mixed methods study are to 1) quantitively identify rates of guideline concordant care (GCC) for colon and gastric cancer among LEP patients versus comparable non-LEP patients treated at UCSD, which serves a significant LEP population as a border-adjacent hospital, and to 2) qualitatively identify facilitators and barriers to GCC for LEP patients. Methods: For our first aim, we identified all UCSD patients diagnosed with colon or gastric cancer between 2012 and 2022 using the University of California Data Warehouse (UCDW). Descriptive analysis was conducted to assess the demographic distribution of the patient cohorts in preparation for our assessment of guideline concordance. For our second aim, semi-structured interviews, based on the Andersen Behavioral Model of Health Services Use framework, were conducted with colon and gastric cancer care providers at UCSD to collect the physician perspective on multilevel factors affecting care for their LEP patients. Results: Our cohort includes 5,403 and 1,777 patients diagnosed with colon and gastric cancer, respectively, at UCSD. Among all patients, 859 (15.9%) colon cancer patients and 423 (23.8%) gastric cancer patients have a preferred language other than English listed in their electronic health record. In both cohorts, significantly more LEP patients than non-LEP patients are on Medicaid insurance: 292 (34.0%) versus 531 (11.7%) colon cancer patients (p < 0.001), and 202 (47.8%) versus 232 (17.1%) gastric cancer patients (p < 0.001). A majority of providers interviewed expressed concerns for more advanced disease presentation in patients with LEP due to the intersection of multiple barriers, including language (100%), health literacy (80%), geographical distance from cancer centers (40%), insurance (40%), and fluctuating border policies (40%). Additional patient-level considerations include cultural norms on bodily integrity and the physician’s prominent social role (60%), which impact shared decision-making. Institution-level barriers include the understaffing and underfunding of supportive staff such as in-person interpreters and patient navigators (100%). Conclusions: Language differences are widely prevalent, augmenting multi-level barriers to care for colon and gastric cancer patient populations served by UCSD. These findings will inform future studies examining the patient experience and designing and implementing an intervention to increase receipt of GCC for LEP patients.