Improving Drug Adherence in the Latino Patient With Diabetes

Kristin Jenkins

January 23, 2017

Two new studies looking at diabetes care in Latino patients have uncovered "intriguing" findings, indicating that there may be more than a language barrier behind "nonadherence" to newly prescribed medication and poor glucose control.

The first study, in almost 31,000 Latino and white patients in the Kaiser Permanente Northern California (KPNC) healthcare system, indicates that 60% of Latino patients with limited English were nonadherent to medication, even though more than half had a fluent Spanish-speaking physician.

The 2-year observational study, which used longitudinal data from January 1, 2006 to December 31, 2012, also reveals that 51.7% of English-speaking Latino patients were noncompliant compared with 37.5% of non-Hispanic white patients.

"Nonadherence to newly prescribed diabetes medications is substantially greater among Latino than white patients, even among English-speaking Latino patients," says the research team, led by Alicia Fernández, MD, of San Francisco General Hospital, California.

And "limited–English-proficiency Latino patients are more likely to be nonadherent than English-speaking Latino patients independent of the Spanish-language fluency of their physicians," they add in their report, published online January 23 in JAMA Internal Medicine.

Moving Beyond Language Barriers

The researchers predict that efforts to improve medication adherence in Latino patients with diabetes will require moving "beyond access to interpreters or patient-physician language concordance."

In an accompanying editorial, Jennifer Alvidrez, PhD, and Eliseo J Pérez-Stable, MD, of the office of the director at the National Institute on Minority Health and Health Disparities at the National Institutes of Health, Bethesda, Maryland, write that these findings run "contrary to expectation" and that "the striking differences by ethnicity and limited English proficiency status remain unexplained."

They note that despite being younger, having fewer comorbidities, and lower copay, Latinos were less adherent than whites, particularly those with low levels of English proficiency.

"This may well be owing to a combination of environmental factors, such as living in more disadvantaged neighborhoods, and cultural factors, such as illness beliefs and cultural norms regarding taking daily medications, diet, and physical activity," they suggest.

While these studies build on earlier findings in Latinos with diabetes and limited English proficiency in the KPNC system, they also "offer intriguing findings regarding the importance of patient-clinician language concordance and suggest areas for future study," the editorialists say.

What's needed now are more studies focused on "Latino attitudes toward chronic disease, cultural factors involved in medication adherence, and other aspects of communication," they explain.

But Language Is Still Important…

Meanwhile, a second study of 1605 Latino adults with diabetes in the KPNC healthcare system showed that the proportion of patients with good glucose control increased from 63% to 74% after one group was switched, between January 1 2007 and December 31, 2013, from an English-speaking doctor to a clinician fluent in Spanish.

This increase was 10% more than the rate observed in a second group of Latino patients who were switched from one English-speaking clinician to another, study leader Melissa Parker, of the division of research at Kaiser Permanente in Oakland, California, said in an email.

The study also showed that poor glucose control decreased by 4% and LDL-cholesterol control improved by 9% when patients with low proficiency in English were switched from an English-speaking physician to a clinician fluent in Spanish.

"Our study suggests that health systems caring for limited–English-proficiency Latinos with diabetes may also improve glycemic control by facilitating language-concordant care, even if it means switching primary-care physicians," the researchers say in their online report, also published online January 23 in JAMA Internal Medicine.

However, "unexpectedly," they add, LDL control improved by 15% in Latino patients who were switched from a physician fluent in Spanish to an English-speaking clinician.

Trust in the healthcare provider or some other factor related to patient satisfaction may have been involved, they suggest.

Language concordance between patients and providers may not be enough to eliminate disparities in medication adherence for Latino patients with diabetes and limited English proficiency, acknowledged Ms Parker in an email.

Still, she added, "Our study shows there are clinical benefits [to language concordance] in addition to improving communication and increasing patient satisfaction.

"Having a primary-care provider that speaks your language" improves lines of communication, reduces risk of misunderstanding, and ups the patient-satisfaction quotient, Ms Parker said.

"Now there is evidence that it may also improve management of diabetes," she told Medscape Medical News.

In their editorial, Drs Alvidrez and Pérez-Stable said these results "provide empirical support that the best strategy to improve the care of limited–English-proficiency Latinos is to increase the number of physicians proficient in Spanish, so that all patients who need or prefer to communicate in Spanish can do so."

Having a clinician fluent in Spanish helps Latino patients "feel better, ask more questions, and report better communication," they note, adding that the findings that glucose control is improved "strengthen this recommendation."

Peer Education Also Has a Role to Play

Still, more research using both qualitative and quantitative methods is needed to better understand the barriers to medication adherence in this patient population, Ms Parker emphasized.

"Identifying the particular financial, social, or cultural barriers in this population and developing policies aimed at eliminating those barriers is the next step," she said.

Indeed, physicians may be missing nonlanguage barriers to adherence, Drs Alvidrez and Pérez-Stable suggest, pointing to the finding that Latino patients who had an English-speaking physician didn't fare any worse than their counterparts with a physician fluent in Spanish.

It also suggests that good diabetes control in Latino patients may not be wholly dependent on a language-concordant clinician.

Cultural scripts that influence the way a Latino patient communicates, his or her treatment preferences, and how trust is generated may also play a role, the editorialists said.

Other studies show that for Latino patients with diabetes, access to resources that support self-management may be just as important as access to diabetes care, they note.

And peer education through community health workers "may be a promising strategy to promote adherence through linguistic and culturally competent care," they suggest.

Drs Alvidrez and Pérez-Stable also point to the need for research in healthcare settings other than the KPNC system that may not have the same capacity for professional interpretation.

Determination of patients who aren't fluent in English should be standardized, they said, adding that even those physicians who claim to be highly fluent in languages other than English should be certified with an oral and written exam.

For example, using Spanish (or other language) fluency as a criterion in medical school or residency acceptance would be one approach, Dr Pérez-Stable told Medscape Medical News.

"We will need to train more Spanish-speaking clinicians to expand access....Physicians also need to be able to write Spanish coherently, which is another level," she added.

Ask the Patient for Their Preferences….

Dr Fernandez advised physicians seeing Latino patients with poor glycemic control to ask if they would like to be switched to a Spanish-speaking healthcare provider.

Clinicians should also focus on medication adherence, regardless of whether the patient is Spanish- or English-speaking, she emphasized.

"Invest in adherence work early in the patient-physician relationship, as it will be time well spent and will build trust if done within the context of supportive, respectful dialogue," Dr Fernandez told Medscape Medical News in an email.

Clinicians should also investigate boundaries, including the patient's opinion about medication — both the specific medication and motivation for diabetes control overall, she said.

Explore any concerns or fears about side effects and whether there are financial barriers. Find out if taking medication several times a day is burdensome.

For the patient who is having difficulty remembering to take medication, physicians should use evidence-based methods such as pill boxes and explore competing demands on the patient's time that may lead to forgetfulness, she concluded.

Funding for the study by Dr Fernandez et al was provided by the National Institute of Diabetes and Digestive and Kidney Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Center for Diabetes Translational Research. The study by Ms Parker et al was supported by a Kaiser Permanente Community Benefit Grant and the National Institute of Diabetes, Digestive and Kidney Diseases. No funding was reported by the editorialists. The authors of both studies as well as the editorialists have no relevant financial relationships.

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JAMA Intern Med. Published online January 23, 2017. Fernández study, Parker study, Editorial

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