Language Barriers, Physician-Patient Language Concordance, and Glycemic Control Among Insured Latinos with Diabetes: The Diabetes Study of Northern California (DISTANCE)
A 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.
To assess the association between limited English proficiency (LEP) and glycemic control and whether this association is modified by having a language-concordant physician.
Cross-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%).
The 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).
Language 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.
- Lasater LM, Davidson AJ, Steiner JF, Mehler PS. Glycemic control in English- vs Spanish-speaking Hispanic patients with type 2 diabetes mellitus. Arch Intern Med. 2001;161(1):77–82. CrossRef
- Mainous Iii AG, Diaz VA, Koopman RJ, Everett CJ. Quality of care for Hispanic adults with diabetes. Fam Med. 2007;39(5):351–356.
- Harris MI. Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes. Diab Care. 2001;24(3):454–459. CrossRef
- CDC. Health disparities experienced by hispanics—United States 2004.
- McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: US trends from 1999 to 2006 and effects of Medicare coverage. Ann Intern Med. 2009;150(8):505–515.
- Hoerger TJ, Segel JE, Gregg EW, Saaddine JB. Is glycemic control improving in US adults? Diab Care. 2008;31(1):81–86. CrossRef
- DeNavas-Walt C, Proctor BD, Smith JC. Current population reports: Income, poverty and health insurance coverage in the United States: 2007. Washington, DC 2008.
- Tseng CW, Tierney EF, Gerzoff RB, et al. Race/ethnicity and economic differences in cost-related medication underuse among insured adults with diabetes: the Translating Research Into Action for Diabetes Study. Diab Care. 2008;31(2):261–266. CrossRef
- US Census Bureau. The American Community-Hispanics: 2004. 2007.
- Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90. CrossRef
- Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med. 2003;18(8):624–633. CrossRef
- Sequist TD, Schneider EC, Anastario M, et al. Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes. J Gen Intern Med. 2008;23(11):1784–1790. CrossRef
- Perez-Stable EJ, Napoles-Springer A, Miramontes JM. The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Med Care. 1997;35(12):1212–1219. CrossRef
- Tocher TM, Larson E. Quality of diabetes care for non-English-speaking patients. A comparative study. West J Med. 1998;168(6):504–511.
- Brown AF, Gregg EW, Stevens MR, 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. Diab Care. 2005;28(12):2864–2870. CrossRef
- Moffet HH, Adler N, Schillinger D, 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. Int J Epidemiol. 2008 Mar 7.
- Karter AJ, Moffet HH, Liu J, 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. Am J Manag Care. 2005;11(4):262–270.
- Fernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence. An exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004;19(2):167–174. CrossRef
- Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005;20(9):800–806. CrossRef
- Zhao Y, Ellis RP, Ash AS, et al. Measuring population health risks using inpatient diagnoses and outpatient pharmacy data. Health Serv Res. 2001;36(6 Pt 2):180–193.
- Saaddine JB, Cadwell B, Gregg EW, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med. 2006;144(7):465–474.
- Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. Bmj. 2000;321(7258):405–412. CrossRef
- Rodondi N, Peng T, Karter AJ, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144(7):475–484.
- Winston GJ, Barr RG, Carrasquillo O, Bertoni AG, Shea S. 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). Diab Care. 2009;32(8):1467–1469. CrossRef
- Morales LS, Cunningham WE, Brown JA, Liu H, Hays RD. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med. 1999;14(7):409–417. CrossRef
- Cheng EM, Chen A, Cunningham W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med. 2007;22(Suppl 2):283–288. CrossRef
- Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, Levinson W, Thisted RA. Impact of interpreter services on delivery of health care to limited-English-proficient patients. J Gen Intern Med. 2001;16(7):468–474. CrossRef
- Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–754. CrossRef
- Gany F, Leng J, Shapiro E, et al. Patient satisfaction with different interpreting methods: a randomized controlled trial. J Gen Intern Med. 2007;22(Suppl 2):312–318. CrossRef
- Baker DW, Hayes R, Fortier JP. Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Med Care. 1998;36(10):1461–1470. CrossRef
- Diamond LC, Reuland DS. Describing physician language fluency: deconstructing medical Spanish. Jama. 2009;301(4):426–428. CrossRef
- Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256–262. CrossRef
- Ferguson WJ. Un poquito. Health Aff (Millwood). 2008;27(6):1695–1700. CrossRef
- Schenker Y, Wang F, Selig SJ, Ng R, Fernandez A. The impact of language barriers on documentation of informed consent at a hospital with on-site interpreter services. J Gen Intern Med. 2007;22(Suppl 2):294–299. CrossRef
- Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007;22(Suppl 2):324–330. CrossRef
- Green AR, Ngo-Metzger Q, Legedza AT, Massagli MP, Phillips RS, Iezzoni LI. Interpreter services, language concordance, and health care quality. Experiences of Asian Americans with limited English proficiency. J Gen Intern Med. 2005;20(11):1050–1056. CrossRef
- Rivadeneyra R, Elderkin-Thompson V, Silver RC, Waitzkin H. Patient centeredness in medical encounters requiring an interpreter. Am J Med. 2000;108(6):470–474. CrossRef
- Karliner LS, Perez-Stable EJ, Gildengorin G. The language divide. The importance of training in the use of interpreters for outpatient practice. J Gen Intern Med. 2004;19(2):175–183. CrossRef
- Campos C. Addressing cultural barriers to the successful use of insulin in Hispanics with type 2 diabetes. South Med J. 2007;100(8):812–820.
- Sentell T, Shumway M, Snowden L. Access to mental health treatment by English language proficiency and race/ethnicity. J Gen Intern Med. 2007;22(Suppl 2):289–293. CrossRef
- Schenker Y, Karter A, Schillinger D, et al. The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with Diabetes: the DISTANCE Study. Patient Educ Couns. 2010(epub.).
- Brown AF, Gerzoff RB, Karter AJ, et al. Health behaviors and quality of care among Latinos with diabetes in managed care. Am J Public Health. 2003;93(10):1694–1698. CrossRef
- Aron D, Pogach L. Transparency standards for diabetes performance measures. Jama. 2009;301(2):210–212. CrossRef
- Weinick RM, Jacobs EA, Stone LC, Ortega AN, Burstin H. Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population. Med Care. 2004;42(4):313–320. CrossRef
- Mainous AG 3rd, Diaz VA, Saxena S, Geesey ME. Heterogeneity in management of diabetes mellitus among Latino ethnic subgroups in the United States. J Am Board Fam Med. 2007;20(6):598–605. CrossRef
- Bash LD, Selvin E, Steffes M, Coresh J, Astor BC. 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. Arch Intern Med. 2008;168(22):2440–2447. CrossRef
- Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577–1589. CrossRef
- Fernandez A, Viloria J, Wu E, Martinez M, Wang F, Selig S. The impact of race/ethnicity and language on access and experience of care among California’s commercially insured adults. February 2007.
- Baker DW, Cameron KA, Feinglass J, et al. A system for rapidly and accurately collecting patients’ race and ethnicity. Am J Public Health. 2006;96(3):532–537. CrossRef
- Selby JV, Swain BE, Gerzoff RB, et al. Understanding the gap between good processes of diabetes care and poor intermediate outcomes: Translating Research into Action for Diabetes (TRIAD). Med Care. 2007;45(12):1144–1153. CrossRef
- Caban A, Walker EA. A systematic review of research on culturally relevant issues for Hispanics with diabetes. Diabetes Educ. 2006;32(4):584–595. CrossRef
- Hatcher E, Whittemore R. Hispanic adults’ beliefs about type 2 diabetes: clinical implications. J Am Acad Nurse Pract. 2007;19(10):536–545. CrossRef
- Huang ES, Brown SE, Thakur N, et al. Racial/ethnic differences in concerns about current and future medications among patients with type 2 diabetes. Diab Care. 2009;32(2):311–316. CrossRef
- Sullivan LV, Hicks P, Salazar G, Robinson CK. Patient beliefs and sense of control among spanish-speaking patients with diabetes in Northeast Colorado. J Immigr Minor Health. 2009 Mar 6.
- Mainous AG 3rd, Diaz VA, Geesey ME. Acculturation and healthy lifestyle among Latinos with diabetes. Ann Fam Med. 2008;6(2):131–137. CrossRef
- Gordon NP, Iribarren C. 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. BMC Public Health. 2008;8:305. CrossRef
- Mainous AG 3rd, Majeed A, Koopman RJ, et al. Acculturation and diabetes among Hispanics: evidence from the 1999–2002 National Health and Nutrition Examination Survey. Public Health Rep. 2006;121(1):60–66.
- Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. Jama. 2002;288(4):475–482. CrossRef
- Gross R, Olfson M, Gameroff MJ, et al. Depression and glycemic control in Hispanic primary care patients with diabetes. J Gen Intern Med. 2005;20(5):460–466. CrossRef
- Schenker Y, Lo B, Ettinger KM, Fernandez A. Navigating language barriers under difficult circumstances. Ann Intern Med. 2008;149(4):264–269.
- U.S. Census Bureau. Census 2000, Summary File 3. Accessed July 10, 2009
- California Health Interview Survey. www.chis.ucla.edu. UCLA Center for Health Policy \Accessed July 2009.
- Language Barriers, Physician-Patient Language Concordance, and Glycemic Control Among Insured Latinos with Diabetes: The Diabetes Study of Northern California (DISTANCE)
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Journal of General Internal Medicine
Volume 26, Issue 2 , pp 170-176
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- limited English proficiency
- health disparities
- health communication
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- Author Affiliations
- 1. Department of Medicine, University of California, San Francisco, CA, USA
- 6. UCSF, Box 1364, San Francisco, CA, 94143, USA
- 2. UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA, USA
- 3. California Diabetes Program, California Department of Public Health, San Francisco, CA, USA
- 4. Division of Research, Kaiser Permanente, Oakland, CA, USA
- 5. Department of Psychiatry, University of California, Oakland, CA, USA