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Systematic review
Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis
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  1. Janet N Chu1,
  2. Jeanette Wong2,
  3. Naomi S Bardach3,4,
  4. Isabel Elaine Allen5,
  5. Jill Barr-Walker6,
  6. Maribel Sierra2,7,
  7. Urmimala Sarkar1,2,
  8. Elaine C Khoong1,2
  1. 1 Medicine, University of California San Francisco, San Francisco, California, USA
  2. 2 Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
  3. 3 Pediatrics, University of California San Francisco, San Francisco, California, USA
  4. 4 Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
  5. 5 Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
  6. 6 Zuckerberg San Francisco General Hospital and Trauma Center Library, San Francisco, California, USA
  7. 7 Tendo, San Francisco, California, USA
  1. Correspondence to Dr Elaine C Khoong, Medicine, University of California San Francisco, San Francisco, California, USA; Elaine.Khoong{at}ucsf.edu

Abstract

Background and objective Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates.

Data sources Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used.

Study selection Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only).

Data extraction and synthesis Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis.

Main outcome(s) and measure(s) Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period.

Results We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications.

Discussion Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients.

PROSPERO registration number CRD42022302871.

  • emergency department
  • healthcare quality improvement
  • patient-centred care

Data availability statement

Data are available on reasonable request. The corresponding author can be contacted for any datasets created for this review.

https://doi.org/10.1136/bmjqs-2023-016295

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    WHAT IS ALREADY KNOWN ABOUT THIS TOPIC

    • Prior studies have shown that language discordance impacts patient-clinician communication and patient ease of accessing care, but studies are conflicting about whether language discordance for patients or parents of paediatric patients increased hospital readmissions or unplanned emergency department (ED) revisits.

    WHAT THIS STUDY ADDS

    • In a meta-analysis, we found that adult patients with non-dominant language preferences had higher odds of hospital readmissions and unplanned ED revisits compared with those without these language-related barriers, but adult patients provided with interpretation services did not have higher odds of hospital readmissions.

    • Paediatric patients with parents with a non-dominant language preference also had higher odds of ED revisits at 72 hours and at 7 days in a meta-analysis.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

    • Given the increase in global migration, there are likely more clinical situations when adult or paediatric patients had language-related communication barriers.

    • These findings demonstrate the critical need to identify patients who may experience language-related communication barriers as well as the value of providing language access services to improve outcomes for language discordant populations.

    Introduction

    Global migration has skyrocketed, with over 272 million international migrants in 2019,1 resulting in increasing linguistic diversity in many countries. This has brought about unprecedented levels of language-related barriers during clinical interactions.2 In order to promote high-quality care, limit adverse events and minimise disparities in access and outcomes, healthcare systems should provide culturally and linguistically tailored resources for language discordant interactions with patients and families.3 Much of the prior literature has been based in English-speaking countries, and these populations have frequently been described as having limited English proficiency (LEP); in recognition of the global nature of this challenge, including in countries where English is not the dominant language, we will use the terms ‘language discordant/discordance’ or ‘non-dominant language preference’.

    Patients and families who are language discordant with their clinical teams report lower patient satisfaction, worse health status and lower rates of having a regular healthcare provider and obtaining preventive care services.4–13 When patients and parents with a non-dominant language preference access care, they report difficulty communicating and understanding medical information from providers, comprehending written medical information, reading prescription bottles and accessing interpretation services.14–24 Individuals with non-dominant language preferences have also been shown to experience more medical errors and adverse health events.25 26

    Adult and paediatric patients impacted by language-related barriers are particularly vulnerable during care transitions, including transitions from the hospital or emergency department (ED) to home. In one prospective study of patients discharged from the hospital, 20% of patients had adverse events within 2 weeks after discharge.27 These adverse events are often associated with readmissions and ED revisits, resulting in increased costs and worse patient experience and outcomes. Consequently, increasing efforts are focused on reducing readmissions.28 Language discordance may contribute to avoidable hospital readmissions and ED revisits through a number of factors, including limited understanding about discharge or medication instructions or lower rates of outpatient follow-up leading to delays in care.29–32

    Prior studies conflict about whether language discordance impacts rates of hospital readmission and ED revisits for either adult or paediatric patients.23 33–37 However, many studies have been limited by sample size, evaluating a single site or specific conditions, or including only participants with non-dominant language preferences (without a comparison group). A recent systematic review exploring clinical outcomes (ie, mortality, length of stay, readmissions/revisits and complications) among hospitalised patients with LEP in English-speaking countries found evidence of higher readmission rates for chronic medical conditions (eg, heart failure) but not for acute medical conditions or procedures; there were mixed findings on unplanned ED revisits.33 However, this review did not include paediatric studies and did not conduct a meta-analysis. Another systematic review of health system-level interventions to improve language access for patients with LEP did not find any studies that measured readmission or ED revisit rates, and in general the studies included in that review focused primarily on process measures.34 A review of interpretation service use in paediatric care settings was similarly inconclusive about clinical outcomes.23

    Given the mixed findings in both the adult and paediatric literature about whether rates of unplanned ED revisits or readmissions are higher for language-discordant interactions and how interpreters impact these outcomes, we aimed to conduct a systematic review and meta-analysis to: (1) explore the association between language discordance (for spoken languages, not signed languages) and unplanned hospital readmissions or ED revisits and (2) assess the impact of interpretation services on disparities in these outcomes between patients with and without non-dominant language preference.

    Methods

    Search strategy

    Our systematic review methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-extension for scoping reviews guidelines38 39 (online supplemental appendix 1 and online supplemental appendix 2). The study and protocol were registered with PROSPERO (CRD42022302871).

    Supplemental material

    Supplemental material

    We developed a search strategy with a clinical librarian (JB-W) using an iterative process that involved testing search terms, keywords and controlled vocabulary, including Medical Subject Headings and Emtree terms, and systematically examining the relevance of corresponding search results. Once testing of the search strategy was completed, we conducted a search for articles involving spoken language discordance and readmissions or ED revisits in PubMed, Embase and Google Scholar on 21 January 2021; we updated this search on 27 October 2022. No date, language or age limits were used. Detailed search strategies for each database can be found in online supplemental appendix 3. In total, we generated 4380 references from all data sources.

    Supplemental material

    Study selection

    We included all articles that met the following inclusion criteria: (1) peer-reviewed publication; (2) reported data on patient or parent language skills/preference and (3) included either unplanned hospital readmission or ED revisit within any timeframe as one of the reported outcomes of the study.

    We excluded articles that were qualitative studies, reviews or case reports with less than five individuals. After contacting five authors to acquire the full text of articles, articles were also excluded that: were a conference abstract only or if we did not have full text of the article, did not contain primary data, or were not available in English (given the language skills of our team). We excluded articles that did not report readmission/ED revisit outcomes stratified by language or interpretation service use. We defined ‘interpretation service use’ as explicit mention of access to or auditing of use of interpretation services by patients with a non-dominant language preference.

    Two reviewers (ECK and JNC) screened 500 titles and abstracts concurrently; once consistency was ensured with a kappa of 0.73, the reviewers divided the remaining studies and screened titles and abstracts separately. For full-text screening, four reviewers (ECK, JNC, MS and JW) independently double-screened the full text of each article. Disagreements about whether studies should be included and differences during data extraction were resolved by consensus among reviewers during team meetings.

    Data extraction

    A standardised form was created to extract data from each study using the Covidence systematic review management software (Veritas Health Innovation, Melbourne, Australia)40 in the following areas: (1) study setting, (2) study type and methodology, (3) characteristics of the participants, (4) characteristics of the intervention, if applicable (eg, intervention type and duration) and (5) outcome measures and results. Four reviewers (ECK, JNC, MS and JW) independently double-extracted data from each article and collaboratively reviewed extracted data regularly to ensure agreement.

    Assessment of risk of bias and quality

    The Newcastle-Ottawa Scale (NOS) was used for quality assessment in three dimensions (patient selection, comparability and outcome) to determine overall quality.41 ,42 NOS is a validated tool to assess risk of bias and quality for cohort studies by evaluating cohort selection, cohort compatibility and assessment of outcomes. We modified NOS for non-cohort studies, similar to the adaptation by Modesti et al.43 The NOS score ranges from 0 to 9, with a higher score indicating higher-quality studies. A score of 7 or more points (≥3 points in the selection domain, ≥2 points in the comparability domain and ≥2 points in the outcome domain) is accepted as good quality rating.44 Four reviewers (ECK, JNC, MS and JW) independently double-extracted data on study quality and resolved disagreements by consensus.

    Data analysis

    We conducted meta-analyses of adult patient studies on two outcomes: (a) 28-day or 30-day hospital readmission and (b) 30-day ED revisits. Both analyses evaluated differences in outcomes based on whether patients had a dominant language preference or not. Given the importance of interpretation services at mitigating challenges in language discordant patient-clinician relationships, we also conducted two subgroup analyses of the readmission outcome: (a) among only studies that provided interpretation service access or verified interpretation service usage among patients with a non-dominant language preference and (b) among studies in which interpretation service access or use was not specified.

    We conducted meta-analyses of paediatric studies on: (a) 72-hour ED revisit and (b) 7-day ED revisits. Both analyses evaluated differences in outcomes based on whether children’s parents had a non-dominant language preference or not. We did not conduct meta-analyses for hospital readmission among paediatric studies since fewer than three studies had the same outcome and heterogeneity was relatively high.45

    Studies that included regression results for separate patient groups were included multiple times (referred to as ‘references’ in the results).46 For example, a study that separately reported results for patients admitted with chronic obstructive pulmonary disease versus patients admitted with congestive heart failure47 had the respective regression estimates included separately in the meta-analysis, and each of those separate estimates are different ‘references’. Patient groups were included as separate references when they were independent groups of patients in the same study, without any overlap with other patients groups, that is, data from these patients were gathered separately and not correlated (eg, Chinese-speakers only vs Spanish-speakers only). DerSimonian and Laird random-effects models were used to perform the meta-analyses. Heterogeneity was assessed using the I2 statistic, and risk of bias was evaluated with both Begg’s test and Egger’s test and a funnel plot, which found no publication bias (p>0.35). We performed a sensitivity analysis to identify outlier studies by using a jackknife method,48 where we left out one study at a time and recalculated the overall meta-analysis to ensure that eliminating a study did not change the summary statistic. Using this approach, no outlier studies were found, and all studies were included in the meta-analysis. All analyses were done using Stata V.16.0 (College Station, Texas, USA).

    Results

    The literature search yielded 4380 articles. After excluding duplicates, 3000 articles were screened for inclusion based on title and abstract, with 1941 eliminated after title/abstract screening, 8 excluded as we were unable to find full text and 1002 excluded based on exclusion criteria after full-text review. Forty-nine studies were included, as indicated in the PRISMA flow chart (figure 1).

    Figure 1
    Figure 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart.119

    Characteristics and participant traits in included studies

    Table 1 reports characteristics of the 49 studies (see online supplemental appendix 4 for more details). Thirty-six were conducted in the USA,36 37 49–82 eight in Australia,83–90 four in Canada47 91–93 and one in Switzerland.94 Except for three studies that used both English and French as the dominant language, all studies focused exclusively on patients with LEP.91–93 The majority were observational studies; five studies were non-randomised experimental studies.50 51 62 82 93 Thirty-six studies evaluated adult patients,47 51–56 59–63 65–69 71–81 83–86 88 89 92 94 12 focused on paediatric patients36 37 49 50 57 58 64 70 82 90 91 93 and one included both adults and paediatric patients.87

    View this table:
    Table 1

    Study characteristics of studies with adult patients who are language discordant with their clinical teams compared with those who are not

    Although most studies included hospitalised patients from the general medicine service, 17 of the adult studies focused on specific chief complaints or procedures (ie, patients with cholecystitis or who received percutaneous coronary intervention).55 56 60 63 68 69 71 73 75–77 79 80 85 88 89 94 Other studies focused on community-dwelling adults receiving home healthcare,78 adults receiving long-term care,92 or a cohort of older community-based adults.74

    The studies that evaluated readmission among paediatric patients included: three studies of patients who received care in the hospital,37 70 90 one of outpatients receiving tele-home care,94 and one of children with preterm birth or very low birth weight.49

    Studies defined language discordance in many ways. Approaches included the patient’s or parent’s (if paediatric population) self-report of primary language or language preference (41 studies); billing event or need for interpretation services noted in the electronic health record (EHR) (14 studies); or an assessment of language proficiency using a standardised questionnaire (2 studies).

    Twenty-eight studies included hospital readmission as the outcome of interest,37 49 52–55 61–63 66 68–70 72–78 83–86 89 90 93 94 13 had ED revisit,36 50 56–59 64 65 80–82 87 91 and 8 had both readmission and ED revisit.47 51 60 67 71 79 88 92 The timeframe of hospital readmissions ranged from 7 to 365 days, while ED revisits ranged from 72 hours to 365 days.

    Quality of included studies

    Tables 1–3 shows the NOS quality assessment of the 49 studies. A majority (33 studies) had a score of 7 or higher.36 37 47 52–62 64–69 72–74 77 78 83 84 87 88 90–92 94 Studies with the lowest scores had issues related to selection (representativeness of the cohort, sample size), comparability (controlling for potential confounding factors) and outcome (assessment of outcome) (see online supplemental appendix 5 for more details).

    Supplemental material

    View this table:
    Table 2

    Study characteristics of studies with paediatric patients with parents who are language discordant with their child’s clinical teams compared with those who do not

    View this table:
    Table 3

    Study characteristics of studies with only patients who are language discordant with their clinical teams

    Hospital readmissions

    Adult patients

    Of the 31 adult studies that evaluated hospital readmissions, 11 (online supplemental appendix 4, table 4A) found a statistically significant association between language discordance and hospital readmission. In our meta-analysis (figure 2) of 30 references from 18 adult studies, we found increased odds of 28-day or 30-day hospital readmissions among those with a non-dominant language preference (OR 1.11, 95% CI 1.04 to 1.18) compared with those with a dominant language preference.

    Figure 2
    Figure 2

    Meta-analysis of studies that evaluated differences in 28-day or 30-day hospital readmission rate among adult patients with versus without a dominant langauge preference, stratified by studies that provided interpreter access or verified interpreter usage among patients with non-dominant language preference versus studies in which interpreter access or use was not specified. COPD, chronic obstructive pulmonary disease.

    Adult patients: stratified by interpretation service use

    In the analysis that separately evaluated studies where it was known that interpretation services were provided for patients with non-dominant language preference versus studies where it was unknown whether interpretation services were provided, we found among the four references from two studies that provided interpretation service access or verified interpretation service usage, there was no statistically significant difference in hospital readmission (OR 0.90, 95% CI 0.77 to 1.05, figure 2 bottom half) compared with those with a dominant language preference. In contrast, among 26 references from 17 studies in which interpretation service access or use was not specified, adults with non-dominant language preference had higher odds of hospital readmission (OR 1.14, 95% CI 1.06 to 1.22, figure 2 top half) compared with those with a dominant language preference.

    Paediatric patients

    In the paediatric population, three studies conducted multivariable analyses examining the association between parental non-dominant language preference and hospital readmissions (figure 3). None of the studies had statistically significant results.

    Figure 3
    Figure 3

    Studies that included hospital readmission among paediatric patients with versus without parental dominant language preference.

    Emergency department revisits

    Adult patients

    Among studies that evaluated ED revisits among adults with non-dominant language preference, less than half (6 of 13) found a statistically significant difference between patients with versus without a dominant language preference. Our meta-analysis (figure 4) of 14 references from 7 adult studies of 30-day ED revisits found that patients with a non-dominant language preference had higher odds of unplanned ED revisits (OR 1.07, 95% CI 1.00 to 1.15).

    Figure 4
    Figure 4

    Meta-analysis of studies that evaluated differences in 30-day emergency department revisit rate among adult patients with versus without dominant language preference. COPD, chronic obstructive pulmonary disease.

    Paediatric patients

    Of five paediatric studies that evaluated ED revisits, two found a statistically significant difference among paediatric patients with parental non-dominant language preference compared with those without. In our meta-analysis, we found a statistically significant difference in odds of ED revisits within 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and within 7 days (OR 1.02, 95% CI 1.01 to 1.03) among paediatric patients whose parents did or did not have a dominant language preference (figure 5).

    Figure 5
    Figure 5

    Meta-analysis of studies that evaluated differences in (1) 7-day emergency department (ED) revisit rate among paediatric patients with non-dominant language preference compared with those without parental non-dominant language preference and (2) 72-hour ED revisit rate among paediatric patients with parental non-dominant language prefernece compared with those without parental non-dominant language preference.

    Discussion

    In this review that explored the role of language discordance on hospital readmissions and unplanned ED revisits, although results from individual studies were mixed, our meta-analysis demonstrated higher odds of 28-day or 30-day hospital readmission among adults with a non-dominant language preference. Moreover, studies that increased access to or validated use of interpretation services for language discordant adult patients found no difference in hospital readmission while those that did not specify interpretation service access/use for language discordant patients had higher odds of readmission for patients with non-dominant language preference. We also found higher odds of unplanned ED revisit within 30 days for adults with non-dominant language preference and higher odds of ED revisit at 72 hours and 7 days for paediatric patients with parents who had a non-dominant language preference.

    Our findings demonstrate that language discordance for adult patients and parents of paediatric patients is associated with greater odds of readmission and/or ED revisit, which is consistent with a prior review that found higher rates of readmission for adults admitted for chronic medical conditions.33 We expand on prior reviews23 33 34 by quantitatively demonstrating that: (a) both adult and paediatric unplanned ED revisit rate is also higher when language discordance exists and (b) access to interpretation services may mitigate the impact of language discordance on disparities in adult readmission rates.

    One key finding from this study and other reviews23 33 34 is that literature on the impact of language discordance on clinical or utilisation outcomes is still quite limited, much less the impact of language access interventions on these outcomes. Few studies of interventions to address language discordance, such as providing professional interpretation services, have focused on clinical or utilisation outcomes.34 In our study, there was no difference in odds of hospital readmission in studies that provided interpretation service access or verified interpretation service use, suggesting that interpretation services may play an important role in reducing readmissions in this underserved population. This expands on prior studies that have also shown that professional interpretation services decrease communication errors, improve quality of care and increase patient satisfaction.34 95 Professional interpretation services may mitigate disparities in care and clinical outcomes when patient-clinician language discordance exists, highlighting the importance of investing in language access resources. However, future research is needed to better understand how language discordance and interventions such as professional interpretation services impact clinical outcomes and quality of care. Since many of these studies are single-site studies, it is crucial for studies to have similar outcomes so that meta-analyses can be more easily conducted.

    The inadequate evaluation of the impact of language discordance on utilisation and clinical outcomes is particularly dire in the paediatric setting. There were a limited number of studies evaluating hospital readmission in the paediatric population, and the studies were heterogeneous in terms of the timeframe, prohibiting synthesis in a meta-analysis. The weak evidence base for paediatric patients further impedes our ability to establish causal relationships between language discordance and hospital readmissions. In addition, paediatric patients are less likely to be readmitted, which may limit the ability to detect differences between groups.96 97 More studies need to be done to understand the impact of parental language discordance on hospital readmissions or other more paediatric-relevant utilisation outcomes.

    Future studies should also pay deliberate intention to how language discordance is defined. The studies included in this review varied in their approach to identifying language discordance, ranging from self-report on a survey to language preference denoted in the EHR to a billing code for interpretation service. Self-report of language preference and need for interpretation services has been recommended by many organisations as the ‘gold standard’.98–100 However, reporting of language preference is complex, for example, patients may report a dominant language preference because they are concerned about being discriminated against or receiving substandard care.101 102 In addition, individuals who speak multiple languages may prefer different languages for different activities. EHRs, particularly in settings with high rates of EHR adoption, have the potential to be an effective approach to collecting data on language preference and needs. However, lack of interoperability and challenges with sharing information across different healthcare providers limit the impact of this approach.103 Moreover, the reliability and quality of the language data collected are suboptimal and can vary significantly.104–107 This is particularly the case for paediatric patients, when it is unknown if the language preference reflects an adolescent’s versus parent’s language preference.108 This highlights the lack of standardisation of collecting data on adult and paediatric patients’ language needs and a need for both health systems and researchers to implement a more uniform approach to identifying patients who experience language discordance-related barriers to healthcare and whose specific language preferences (eg, a patient vs a parent) is most impactful on clinical outcomes.

    One key challenge to interpreting and analysing studies on how language discordance impacts clinical care is the complex relationship between language, race/ethnicity, migration status and socioeconomic status.109–111 Through classism, racism and xenophobia, these intersectional identities also impact quality of care, patient-reported outcomes and clinical outcomes.110 112 113 Moreover, despite global migration to many non-English-speaking countries and the consequent language barriers that exist in healthcare,114–117 we have limited insights on how language discordance impacts care worldwide or more broadly how the dynamics of cultural, race/ethnicity and language differ in other countries.118 Studies on the impact of language discordance on health equity need to better understand the exact mechanisms on how language discordance impacts care and how this intersects with other characteristics, such as race/ethnicity, migration status, country of origin or socioeconomic status, which also may impact care through the same mechanisms.113

    This review was limited in several ways. The studies in our review were conducted in the USA, Australia, Canada and Switzerland, and our findings may not be generalisable to other countries. In addition, we relied primarily on single-reviewer screening of title and abstract, although we double-screened until we achieved an appropriate inter-rater reliability. While we included one study that had patients that were deaf/hard of hearing (DHH), we did not explicitly include DHH in our search term for patients with non-dominant language preference; therefore, our study did not include a comprehensive review of studies of patients that were DHH. Given the limited evidence in the paediatric literature, we have much less understanding of the causal relationships between language discordance and our studied outcomes. Furthermore, given the language skills of our team, most studies included in this review were conducted in English-speaking countries; we excluded studies that were not available in English, and it is possible that we missed studies published in non-English language journals. We were also limited by our inability to acquire full text for several articles, although we did attempt to contact authors, we did not receive a response from all the authors. Finally, the studies included were somewhat heterogeneous (due to differences in study design, ascertainment of language discordance, sample size, study participant inclusion criteria, assessment/provision of language access, timing of outcome assessment). This limits our ability to precisely quantify the association between language discordance and the studied outcomes.

    In conclusion, adult patients with non-dominant language preference experience higher hospital readmission and ED revisit rates compared with those without non-dominant language preference, while paediatric patients with parental non-dominant language preference are more likely to have unplanned ED revisits. Providing high-quality interpretation services may mitigate some of these disparities. Given the increase in global migration and prevalence of language discordance, it is imperative that healthcare systems and researchers improve efforts to identify when language discordance exists and mitigate the impact of language discordance-related barriers on health equity.

    Supplemental material

    Data availability statement

    Data are available on reasonable request. The corresponding author can be contacted for any datasets created for this review.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Footnotes

    • X @janetnchu, @naomibardach, @DataCooker, @UrmimalaSarkar, @elainekhoong

    • Contributors Study conception and design: JC, US, NSB, ECK. Data collection: JC, MS, JW, ECK. Analysis and interpretation of results: all authors. Draft and manuscript preparation: JC. All authors reviewed the results and approved the final version of the manuscript. ECK is the guarantor for this manuscript.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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