Language Barriers, Physician-Patient Language Concordance, and Glycemic Control Among Insured Latinos with Diabetes: The Diabetes Study of Northern California (DISTANCE)

ABSTRACTBACKGROUNDA significant proportion of US Latinos with diabetes have limited English proficiency (LEP). Whether language barriers in health care contribute to poor glycemic control is unknown.OBJECTIVETo assess the association between limited English proficiency (LEP) and glycemic control and whether this association is modified by having a language-concordant physician.DESIGNCross-sectional, observational study using data from the 2005–2006 Diabetes Study of Northern California (DISTANCE). Patients received care in a managed care setting with interpreter services and self-reported their English language ability and the Spanish language ability of their physician. Outcome was poor glycemic control (glycosylated hemoglobin A1c > 9%).KEY RESULTSThe unadjusted percentage of patients with poor glycemic control was similar among Latino patients with LEP (n = 510) and Latino English-speakers (n = 2,683), and higher in both groups than in whites (n = 3,545) (21% vs 18% vs. 10%, p < 0.005). This relationship differed significantly by patient-provider language concordance (p < 0.01 for interaction). LEP patients with language-discordant physicians (n = 115) were more likely than LEP patients with language-concordant physicians (n = 137) to have poor glycemic control (27.8% vs 16.1% p = 0.02). After controlling for potential demographic and clinical confounders, LEP Latinos with language-concordant physicians had similar odds of poor glycemic control as Latino English speakers (OR 0.89; CI 0.53–1.49), whereas LEP Latinos with language-discordant physicians had greater odds of poor control than Latino English speakers (OR 1.76; CI 1.04–2.97). Among LEP Latinos, having a language discordant physician was associated with significantly poorer glycemic control (OR 1.98; CI 1.03–3.80).CONCLUSIONSLanguage barriers contribute to health disparities among Latinos with diabetes. Limited English proficiency is an independent predictor for poor glycemic control among insured US Latinos with diabetes, an association not observed when care is provided by language-concordant physicians. Future research should determine if strategies to increase language-concordant care improve glycemic control among US Latinos with LEP.

[1]  D. Aron,et al.  Transparency standards for diabetes performance measures. , 2009, Journal of the American Medical Association (JAMA).

[2]  N. Gordon,et al.  Health-related characteristics and preferred methods of receiving health education according to dominant language among Latinos Aged 25 to 64 in a large Northern California health plan , 2008, BMC public health.

[3]  I. Motola,et al.  Patient Satisfaction with Different Interpreting Methods: A Randomized Controlled Trial , 2007, Journal of General Internal Medicine.

[4]  John D. Piette,et al.  Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population , 2003, Journal of General Internal Medicine.

[5]  E. Larson,et al.  Quality of diabetes care for non-English-speaking patients. A comparative study. , 1998, The Western journal of medicine.

[6]  E. Vittinghoff,et al.  Therapy Modifications in Response to Poorly Controlled Hypertension, Dyslipidemia, and Diabetes Mellitus , 2006, Annals of Internal Medicine.

[7]  W. Levinson,et al.  Impact of interpreter services on delivery of health care to limited-English-proficient patients , 2001, Journal of General Internal Medicine.

[8]  P. Hicks,et al.  Patient Beliefs and Sense of Control Among Spanish-Speaking Patients with Diabetes in Northeast Colorado , 2010, Journal of Immigrant and Minority Health.

[9]  J. Steiner,et al.  Glycemic control in English- vs Spanish-speaking Hispanic patients with type 2 diabetes mellitus. , 2001, Archives of internal medicine.

[10]  C. Campos.  Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics with Type 2 Diabetes , 2007, Southern medical journal.

[11]  R. Koopman,et al.  Quality of care for Hispanic adults with diabetes. , 2007, Family medicine.

[12]  A. Stewart,et al.  Physician language ability and cultural competence. An exploratory study of communication with Spanish-speaking patients. , 2004, Journal of general internal medicine.

[13]  Alicia Fernandez,et al.  The Impact of Language Barriers on Documentation of Informed Consent at a Hospital with On-Site Interpreter Services , 2007, Journal of General Internal Medicine.

[14]  S. Saxena,et al.  Heterogeneity in Management of Diabetes Mellitus Among Latino Ethnic Subgroups in the United States , 2007, The Journal of the American Board of Family Medicine.

[15]  Eric M. Cheng,et al.  Primary Language and Receipt of Recommended Health Care Among Hispanics in the United States , 2007, Journal of General Internal Medicine.

[16]  Ron D. Hays,et al.  Are latinos less satisfied with communication by health care providers? , 1999, Journal of General Internal Medicine.

[17]  B. D. Proctor,et al.  Current Population Reports, P60-235, Income, Poverty, and Health Insurance Coverage in the United States: 2007 , 2008 .

[18]  E. Perez-stable,et al.  The language divide. The importance of training in the use of interpreters for outpatient practice. , 2004, Journal of general internal medicine.

[19]  K. Grumbach,et al.  Effects of limited English proficiency and physician language on health care comprehension , 2005, Journal of General Internal Medicine.

[20]  Jesse C. Crosson,et al.  Race/Ethnicity and Economic Differences in Cost-Related Medication Underuse Among Insured Adults With Diabetes , 2007, Diabetes Care.

[21]  Romain Neugebauer,et al.  Cohort Profile: The Diabetes Study of Northern California (DISTANCE)--objectives and design of a survey follow-up study of social health disparities in a managed care population. , 2009, International journal of epidemiology.

[22]  D W Baker,et al.  Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. , 1998, Medical care.

[23]  E. Kinney,et al.  Health Insurance Coverage in the United States , 2002 .

[24]  R. Koopman,et al.  Acculturation and Diabetes among Hispanics: Evidence from the 1999–2002 National Health and Nutrition Examination Survey , 2006, Public health reports.

[25]  E. Walker,et al.  A Systematic Review of Research on Culturally Relevant Issues for Hispanics With Diabetes , 2006, The Diabetes educator.

[26]  Melissa M. Parker,et al.  Achieving good glycemic control: initiation of new antihyperglycemic therapies in patients with type 2 diabetes from the Kaiser Permanente Northern California Diabetes Registry. , 2005, The American journal of managed care.

[27]  R. Holman,et al.  10-year follow-up of intensive glucose control in type 2 diabetes. , 2008, The New England journal of medicine.

[28]  Arleen F. Brown,et al.  Health behaviors and quality of care among Latinos with diabetes in managed care. , 2003, American journal of public health.

[29]  R. Hasnain-Wynia,et al.  A system for rapidly and accurately collecting patients' race and ethnicity. , 2006, American journal of public health.

[30]  L. Diamond,et al.  Describing physician language fluency: deconstructing medical Spanish. , 2009, JAMA.

[31]  D. Meltzer,et al.  Racial/Ethnic Differences in Concerns About Current and Future Medications Among Patients With Type 2 Diabetes , 2009, Diabetes Care.

[32]  Health disparities experienced by Hispanics--United States. , 2004, MMWR. Morbidity and mortality weekly report.

[33]  Thomas D. Sequist,et al.  Quality Monitoring of Physicians: Linking Patients’ Experiences of Care to Clinical Quality and Outcomes , 2008, Journal of General Internal Medicine.

[34]  A. Mainous,et al.  Acculturation and Healthy Lifestyle Among Latinos With Diabetes , 2008, The Annals of Family Medicine.

[35]  L. Karliner,et al.  Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. , 2007, Health services research.

[36]  B. Lo,et al.  Navigating Language Barriers under Difficult Circumstances , 2008, Annals of Internal Medicine.

[37]  R. Barr,et al.  Sex and Racial/Ethnic Differences in Cardiovascular Disease Risk Factor Treatment and Control Among Individuals With Diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA) , 2009, Diabetes Care.

[38]  R. Holman,et al.  Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study , 2000, BMJ : British Medical Journal.

[39]  M. Massagli,et al.  Interpreter services, language concordance, and health care quality , 2005, Journal of General Internal Medicine.

[40]  M. Shumway,et al.  Access to Mental Health Treatment by English Language Proficiency and Race/Ethnicity , 2007, Journal of General Internal Medicine.

[41]  D. Schillinger,et al.  Closing the loop: physician communication with diabetic patients who have low health literacy. , 2003, Archives of internal medicine.

[42]  M. Engelgau,et al.  Improvements in Diabetes Processes of Care and Intermediate Outcomes: United States, 19882002 , 2006, Annals of Internal Medicine.

[43]  E. Bradley,et al.  Getting By: Underuse of Interpreters by Resident Physicians , 2009, Journal of General Internal Medicine.

[44]  N. Adler,et al.  The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE study. , 2010, Patient education and counseling.

[45]  B. Clarridge,et al.  Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use , 2007, Journal of General Internal Medicine.

[46]  Arleen F. Brown,et al.  Understanding the Gap Between Good Processes of Diabetes Care and Poor Intermediate Outcomes: Translating Research Into Action for Diabetes (TRIAD) , 2007, Medical care.

[47]  M. Harris,et al.  Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes. , 2001, Diabetes care.

[48]  M. Weissman,et al.  Depression and glycemic control in hispanic primary care patients with diabetes , 2005, Journal of General Internal Medicine.

[49]  E. Jacobs,et al.  Patient centeredness in medical encounters requiring an interpreter. , 2000, The American journal of medicine.

[50]  Arleen F. Brown,et al.  Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study. , 2005, Diabetes care.

[51]  J Z Ayanian,et al.  Measuring population health risks using inpatient diagnoses and outpatient pharmacy data. , 2001, Health services research.

[52]  Ellen Meara,et al.  Differences in Control of Cardiovascular Disease and Diabetes by Race, Ethnicity, and Education: U.S. Trends From 1999 to 2006 and Effects of Medicare Coverage , 2009, Annals of Internal Medicine.

[53]  D. Schillinger,et al.  Association of health literacy with diabetes outcomes. , 2002, JAMA.

[54]  Elizabeth Selvin,et al.  Poor glycemic control in diabetes and the risk of incident chronic kidney disease even in the absence of albuminuria and retinopathy: Atherosclerosis Risk in Communities (ARIC) Study. , 2008, Archives of internal medicine.

[55]  E. Perez-stable,et al.  The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. , 1997, Medical care.

[56]  H. Burstin,et al.  Hispanic Healthcare Disparities: Challenging the Myth of a Monolithic Hispanic Population , 2004, Medical care.

[57]  R. Whittemore,et al.  Hispanic adults’ beliefs about type 2 diabetes: Clinical implications , 2007, Journal of the American Academy of Nurse Practitioners.