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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
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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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Measures

Patient language status was assessed by the following DISTANCE survey question: “How often do you have difficulty understanding or speaking English?” Latino respondents who answered “usually” or “often” were designated as having limited English proficiency (“LEP Latino”), whereas those who responded “sometimes,” “rarely,” or “never” were designated as English-speaking (“English-speaking Latino”). Physician language ability was assessed by response to another DISTANCE survey question: “Without using an interpreter, how well does your personal physician speak your language?” Responses to this question were also dichotomized; participants who answered “well,” “very well,” or “excellent” were considered to have a language-concordant (ie, Spanish-speaking) PCP (LEP-concordant), whereas those who responded “fair,” “poorly,” or “does not speak my language” were considered to have a non–Spanish-speaking language-discordant PCP (LEP-discordant).4 LEP patients who did not respond to the question on physician language proficiency were excluded from the analysis of language concordance.

Other measures of interest determined from survey responses included demographic information and time since diabetes diagnosis. KPNC data from 2005 were used to generate individual comorbidity scores using the DxCg, a validated risk assessment tool designed to quantify a patient’s illness burden, in which higher numbers indicate greater illness burden.18 Patients whose benefit records showed no gap of greater than 1 month in pharmacy coverage in the year prior to the survey response date were categorized as having continuous pharmacy benefits. Patients were considered to be using antihypertensive medications or lipid-lowering agents if electronic records showed that they were dispensed any prescriptions on a list of commonly used agents in the year prior to the survey.

Outcome Measures

Our 2 main outcome measures were the patients’ most recent measurements of LDL-C and SBP obtained during routine clinical care in the year prior to the survey date. Poor lipid control was defined as LDL-C higher than 100 mg/dL and poor hypertension control as SBP higher than 140 mm Hg, using widely accepted clinical guidelines in place during study years. Secondary outcomes were mean LDL-C and SBP.

Statistical Analyses

We compared characteristics of English-speaking white, English-speaking Latino, and LEP Latino patients using χ2 tests for categorical variables and Student’s t tests for continuous variables. Among the LEP Latino patients, we compared language-discordant and -concordant groups. We compared the odds of poor lipid control and poor SBP control among the different patient groups using generalized estimating equations (GEE) models to account for covariates (age, sex, education, income, diabetes duration, comorbidities, continuous prescription benefits, and control medications) and clustering of patients by physician and healthcare facility. Because of sample size constraints, in the comparison of LEP language-discordant versus LEP language-concordant groups, we used a parsimonious GEE model accounting for clustering by facility and adjusting for age, sex, education, diabetes duration, missing comorbidity score, and control medications. We also specified models that included an interaction term to evaluate whether the LEP-LDL-C or LEP-SBP relationships differed by patient–physician language concordance. To determine if our results were sensitive to our definition of LEP, we repeated our analyses including patients who reported “sometimes” having difficulty with English in the LEP Latino group.

RESULTS

The study population (N = 7359) included 3896 English-speaking white, 2921 English-speaking Latino, and 542 LEP Latino patients. Clustering of LEP patients by physician was not common, as most (90%) of the LEP Latino patients were cared for by a Kaiser physician with 3 or fewer LEP patients in the study (range, 1-17).

English-speaking white, English-speaking Latino, and LEP Latino patients differed in several ways (Table 1). Compared with either of the Latino patient groups, white patients were more likely to be male, report more education, and report greater income. When compared with their LEP counterparts, English-speaking Latino patients were more likely to be male (49.8% vs 36.7%; P = .001), have finished high school (69.8% vs 28.2%; P <.001), have annual incomes of $35,000 or above (56.6% vs 24.2%; P <.001), and have continuous pharmacy benefits during the year prior to the survey (94.6% vs 86.4%; P <.05). Mean comorbidity index values were similar among the 2 Latino patient groups and slightly lower than the mean comorbidity index for English-speaking white patients. Among the LEP patients, LEP-concordant and LEP-discordant groups had similar patient characteristics. English-speaking white patients were somewhat more likely to be dispensed lipid-lowering medications than English-speaking Latino patients (81.3% vs 76.1%; P <.001), who were somewhat more likely to be dispensed these medications than LEP Latino patients (76.1% vs 71.2%; P = .01). A similar pattern across patient groups was observed for antihypertensive medication dispensing.

Slightly more than one-third of all patients had poor LDL-C control, with a recent LDL-C level higher than 100 mg/dL. English-speaking Latino patients were somewhat more likely to have poorly controlled LDL-C than English-speaking white patients in unadjusted analysis (36.8% vs 33.7%; P = .01) (Table 2), whereas differences in lipid control between English-speaking Latino and LEP Latino patients were not statistically significant. We found no differences in lipid control among the LEP Latino patients by patient–physician language concordance. Similar patterns were observed for mean LDL-C by patient group.

Approximately one-fifth of patients had poor SBP control. The unadjusted percentage of patients with poor SBP control did not differ between English-speaking white patients and English-speaking Latino patients (21.7% vs 20.0%; P = .11) or between English-speaking Latino patients and LEP Latino patients (20.0% vs 16.7%; P = .08). Mean SBP was marginally lower (ie, better) in the LEP Latino group than the English-speaking Latino group (130.0 vs 131.4; P = .03).

Multivariate models adjusting for age and sex eliminated the small differences in lipid control between English-speaking white patients and English-speaking Latino patients, and further adjustment for other demographic and clinical factors did not change this finding (Table 3) (adjusted odds ratio [AOR], 1.05; 95% CI, 0.93-1.18). However, among Latinos, LEP patients were less likely than English-speaking patients to have poorly controlled LDL-C (AOR, 0.71; 95% CI, 0.54-0.93). The interaction term for patient–physician language concordance by LEP status was not significant (P >.05), indicating that the LEP-SBP and LEP-LDL-C relationship did not differ according to patient–physician language concordance. Analyses using mean LDL-C and SBP as outcomes in linear GEE models showed similar results. Sensitivity analyses including Latino patients who reported “sometimes” having difficulty with English (n = 598) in the LEP Latino group did not alter the findings (data not shown).


 
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