Diabetes management among Latino patients begins with language-concordant care

Although glycemic control improved among Latino diabetes patients with limited English proficiency when treated by Spanish-speaking primary care physicians, these patients are less likely to adhere to newly prescribed diabetes medications than English-speaking Latino and white patients, according to two studies published today in JAMA Internal Medicine.

“Among patients with diabetes, [limited English proficiency (LEP)] Latinos have higher rates of poor glycemic control than English-speaking Latinos or whites, but this inequality might be mitigated by care from Spanish-speaking (ie, language-concordant) PCPs,” Melissa M. Parker, MS, from the division of research at Kaiser Permanente Northern California, and colleagues wrote. “Patients with language-concordant PCPs have potentially better communication, interpersonal process of care, patient-centeredness, trust, and satisfaction with quality of care.”

Better glycemic control among diabetic LEP Latinos with Spanish-speaking PCPs

Parker and colleagues found that LEP Latino patients with diabetes who switched to Spanish-speaking PCPs saw improvements in glycemic control, suggesting facilitating the language-concordant care can help manage diabetes among LEP Latinos.

They evaluated changes in glycemic, poor glycemic, LDL and systolic BP control among LEP Latinos with diabetes who switched from English-only PCPs to Spanish-speaking PCPs or vice versa in a pre-post, difference-in-difference study. They included 1,605 Latino members of the Kaiser Permanente Norther California health care system with diabetes who preferred Spanish and changed PCPs between Jan. 1, 2007, and Dec. 31, 2013.

Glycemic and LDL control significantly improved among patients who switched from an English-speaking PCP to a Spanish-speaking PCP when compared with those who switched from one discordant PCP to another. The researchers also found that glycemic control increased by 10% (95% CI, 2-17; P = .01), LDL control increased by 9% (95% CI, 1-17; P = .03) and poor glycemic control decreased by 4% (95% CI, –10 to 2; P = .16).

Among LEP Latinos who changed from concordant to discordant PCPs, Parker and colleagues observed that prevalence of LDL control increased 15% (95% CI, 7-24; P < .001). The researchers suspect that these results are due to an improvement in a closely linked but unmeasured aspect of care other than communication such as patient satisfaction or trust in PCP.

“There was no evidence of harm after switching from concordant to discordant PCPs, and in the case of LDL control, these switches also resulted in improvement,” Parker and colleagues wrote. “Health systems caring for LEP Latinos with diabetes may also improve glycemic control by facilitating language-concordant care, even if it means switching PCPs.”

Varied medication adherence among Latino, white patients with diabetes

In a separate observational study, Alicia Fernández, MD, from the division of internal medicine at San Francisco General Hospital, and colleagues found that Latinos showed high levels of initial, early and late-stage medication nonadherence when compared with white patients.

“Language barriers might lead to poorer glycemic control… and physicians may be reluctant to initiate or intensify medications when they are uncertain of a patient’s current medication use,” Fernández and colleagues wrote. “The extent to which language barriers affect medication adherence for newly prescribed medication, and how these potential barriers play out in health care settings with uniform access to professional interpreter services, is not well understood.”

The researchers assessed the association of patient race/ethnicity, preferred language and physician language concordance with Latino patient adherence to newly prescribed diabetes medications. Their study included insured English-speaking white, English-speaking Latino or limited English proficiency Latino patients with newly prescribed type 2 diabetes medications at Kaiser Permanente Northern California from Jan. 1, 2006 to Dec. 31, 2012.

The researchers measured for primary nonadherence (never dispensed), early-stage nonpersistence (dispensed once), late-stage nonpersistence (two or more dispensings, then discontinued within 24 hours) and inadequate overall medication adherence (more than 20% of time without medication supply during 2-years after initial prescription).

Out of 21,878 white, 5,755 English-speaking Latino and 3,205 LEP Latino patients, there were 46,131 prescriptions for new diabetes medications. The researchers found that 4,004 (18.3%) white, 1,565 (27.2%) English-speaking Latino and 1,032 (32.2%) LEP Latino patients were either primary nonadherent or early nonpersistent to oral medications. They observed inadequate overall adherence in 8,204 (37.5%) white, 2,975 (51.7%) English-speaking Latino and 1,929 (60.2%) LEP Latino patients. Early-stage nonpersistence to insulin was 6,235 (28.5%) among white patient, 1,980 (34.4%) among English-speaking Latino patients and 1,372 (42.8%) among LEP Latino patients.

LEP Latinos were more likely to be nonadherent to both oral drugs and insulin compared with English-speaking Latinos (RR = 1.11-1.17; P < .05) and white patients (RR = 1.36-1.49; P < .05). Compared with white patients, English-speaking Latinos were also more likely to be nonadherent (RR = 1.23-1.3; P < .05). Fernández and researchers found that among LEP Latino patients, 1,610 (50.2%) had a PCP fluent in Spanish; however, they reported no association between patient-physician language concordance and the rates of nonadherence among LEP Latino patients.

“More needs to be done to improve adherence to newly prescribed medications among Latino patients at all levels of English proficiency,” Fernandez and colleagues wrote. “Given the lack of evidence of substantive differences in adherence between language-concordant vs language discordant LEP patients, these interventions need to go beyond simply addressing language barriers.”

In an associated editorial, Jennifer Alvidrez, PhD, and Eliseo J. Pérez-Stable, MD, from the National Institute on Minority Health and Health Disparities, wrote that these findings emphasized the importance of patient-clinician language concordance and suggest areas that must be addressed further. Alvidrez and Pérez-Stable explain that to understand the factors that contribute to medication adherence among Latinos with diabetes, integrated health systems should meet undefined sociocultural components.

“There is a need to integrate greater granularity on social determinants into the medical record to provide more precision patient-clinician interactions,” they wrote. – by Savannah Demko

Disclosure: Fernández, Parker, Alvidrez and Pérez-Stable report no relevant financial disclosure.

References:

Alvidrez J, Pérez-Stable EJ. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2016.8661.

Fernández A, et al. JAMA Intern Med. 2017;doi:10. 1001/jamainternmed.2016.8653.

Parker MM, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2016.8648.