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The American Journal of Managed Care September 2018
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Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes
Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
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Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD
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Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes

Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
Among Latino patients with diabetes, ethnicity and language barriers were not associated with lipid and blood pressure control despite their associations with glycemic control in prior research.
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Objectives: Language barriers in healthcare are associated with worse glycemic control among Latino patients with limited English proficiency and diabetes. We examined the association of patient–physician language concordance with lipid (low-density lipoprotein cholesterol [LDL-C]) and systolic blood pressure (SBP) control.

Study Design: Retrospective cohort study.

Methods: Data were obtained from a survey and the electronic health records of Latino and white patients with diabetes receiving care within 1 integrated health plan with interpreter services available. Limited English proficiency and patient–physician language concordance were defined by patient report. Outcomes were poor lipid control (LDL-C >100 mg/dL) and poor SBP control (SBP >140 mm Hg).

Results: In total, 3463 Latino (2921 who spoke English and 542 who were limited English proficient [LEP]) and 3896 English-speaking white patients participated. One-third of the patients had poor lipid control and one-fifth had poor SBP control. English-speaking white patients were slightly less likely to have poor lipid control than English-speaking Latino patients, but the difference did not persist after adjustment for age and sex. Among Latinos, LEP patients were less likely to have poor lipid control than English-speaking patients (odds ratio, 0.71; 95% CI, 0.54-0.93), with no difference by LEP patient–physician language concordance. Poor SBP control did not differ by ethnicity, primary language, or patient–physician language concordance.

Conclusions: We found no evidence that ethnicity or language barriers in healthcare were associated with poorer lipid or blood pressure control among Latino and white patients with diabetes receiving care in settings with professional interpreters.

Am J Manag Care. 2018;24(9):405-410
Takeaway Points

Health systems are struggling to provide effective care and meet quality metrics for the large numbers of Latino patients with diabetes.
  • Language barriers are known to impact patient satisfaction and trust. Recent research indicates that language barriers are associated with poor glycemic control and that switching patients to language-concordant (Spanish-speaking) physicians may improve glycemic control in a population of patients.
  • This study found that language barriers and language concordance are not associated with lipid and blood pressure control.
  • Quality improvement efforts for lipid and blood pressure control should focus on barriers beyond language.
As the number of Latinos with limited English proficiency and diabetes increases,1-3 health plans and physicians need to know if language barriers contribute to diabetes outcomes. Understanding the role of language barriers in health outcomes will assist in workforce planning (ie, hiring of bilingual clinicians) and contribute to quality improvement efforts.

Prior research has reported on the association of language barriers with glycemic control among patients with type 2 diabetes.4-6 Using data from an integrated health plan with language access services available, researchers found that rates of poor glycemic control (glycated hemoglobin >9%) were nearly twice as high among Latino patients compared with white patients, regardless of the Latino patients’ English language proficiency.4 Among limited English proficient (LEP) Latino patients, however, those with a language-discordant (ie, non–Spanish-speaking) physician were nearly twice as likely to have poor glycemic control compared with those who had a language-concordant physician. These differences persisted after adjustment for other demographic and clinical factors. A recent study in the same setting found a 10% increase in the proportion of LEP patients with good glycemic control among those who switched from a language-discordant primary care physician (PCP) to a language-concordant (Spanish-speaking) PCP compared with those who switched from a language-discordant PCP to another language-discordant PCP.7

Control of serum lipid levels and blood pressure is particularly important in diabetes, and over the last 10 years, diabetes care guidelines have underscored the need for monitoring and control of these powerful risk factors for cardiovascular and renal disease among patients with diabetes.8-10 Studies of Latinos with diabetes indicate a complex relationship among acculturation, diet, and exercise,11-14 with several studies finding that LEP Latinos have better lipid profiles than more acculturated English-speaking Latinos. Systolic blood pressure (SBP) may also vary with acculturation, although some study findings suggest no impact.11,15 In this study, however, we focused on the role of language barriers in healthcare and sought to determine the extent to which language barriers between physicians and patients may have impacted lipid and blood pressure control among LEP Latino patients with diabetes. By focusing on an insured population with uniform and continuous access to care, we are better able to isolate any contribution of language barriers to clinical outcomes.


This analysis used data from the Diabetes Study of Northern California (DISTANCE), an NIH-funded survey follow-up cohort study among members of the Kaiser Permanente Northern California (KPNC) Diabetes Registry.16 Conducted in 2005-2006, the DISTANCE survey included 184 questions designed to assess a wide range of social and behavioral factors that may influence diabetes-related outcomes. This survey was offered in multiple modes and languages to a race-stratified random sample of members of the KPNC Diabetes Registry. The survey had a response rate of 62%. DISTANCE was approved by the institutional review boards of the Kaiser Foundation Research Institute and the University of California, San Francisco.


KPNC is a nonprofit integrated healthcare delivery system providing comprehensive medical care to a diverse population of approximately 3.2 million members in Northern California. Distribution of patient demographic and socioeconomic factors is similar to that of the area population except in the extremes of the income distribution.17 Each KPNC facility provides bilingual clinicians and interpreter services through qualified bilingual staff, telephone language interpreters, and on-site professional interpreters for their LEP patients.

Study Population

For this study, we used the same patient cohort as in the study of language and glycemic control by Fernandez et al.4 Study participants were DISTANCE respondents whose self-identified race/ethnicity was Latino (n = 3877) or white (n = 4521). We excluded those who had longer than a 60-day gap in health plan enrollment in the year prior to the survey date (n = 205), who did not have type 2 diabetes (n = 436), who did not respond to the question about their English language proficiency (n = 104), and who did not have either a low-density lipoprotein cholesterol (LDL-C) test or SBP measure (n = 294), leaving a total of 3463 Latinos and 3896 whites. For analysis of LDL-C, respondents who had no LDL-C measure (n = 683), had an abnormal liver function test (aspartate aminotransferase >150) (n = 34), or were missing physician information (n = 86) were also excluded from analysis. For analysis of SBP, respondents who had no SBP measure (n = 385), had end-stage renal disease or glomerular filtration rate less than 15 mL/min/1.73m2 (n = 228), or were missing physician information (n = 49) were also excluded from analysis.

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