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Patient-provider Language Barriers Linked to Worse Diabetes Control

Patients who cannot talk about their diabetes with their doctor in their own language may have poorer diabetes outcomes, even when interpreter services are available, according to a new study by researchers at UCSF and the Kaiser Permanente Division of Research.

The study found that, among Latino diabetes patients with limited English skills, those seen by doctors who did not speak Spanish were nearly twice as likely to have poor control of their blood sugar compared to those whose doctors did speak Spanish.

Findings will appear in the January 2011 issue of the Journal of General Internal Medicine and are available online at

The study, which was conducted among patients with access to interpreters, is the first to link language barriers with worse diabetes-related health outcomes and the first to examine the impact of Spanish speaking physicians on diabetes disparities.  The study did not examine languages other than Spanish.

“Diabetes is a complex disease that requires a high level of patient understanding and engagement for successful management,” said Alicia Fernandez, MD, a UCSF professor of medicine and lead author of the study. “These patients may need direct communication with Spanish-speaking physicians to manage their disease appropriately.”

The team surveyed adults with diabetes who are part of the Diabetes Study of Northern California (DISTANCE), a study of patients from the Kaiser Permanente Northern California Diabetes Registry, and compared rates of blood sugar control among Latino patients whose doctors could or could not converse in Spanish.

Overall, the study found that Latino patients had worse control of their disease than English-speaking Caucasian patients: even English-speaking Latinos had almost double the rates of poor blood sugar control compared to Caucasians.

However, researchers found no difference in blood sugar control between English-speaking Latinos and non-English speaking Latinos who had access to a doctor who spoke their language. When Latinos with limited English skills had a doctor who did not speak Spanish, though, 28 percent of the patients had poor blood sugar control, as opposed to 16 percent of those with a Spanish-speaking physician. Only 10 percent of the Caucasian patients had poor blood sugar control.

According to the 2000 census, more than 8 percent of the U.S. population, or 18 million adults, speak English less than very well,, and the majority (14 million) speak Spanish as their first language. The U.S. Latino population is growing rapidly and has one of the highest rates of diabetes.

“The study adds to evidence that the conversation between physician and patient is of critical importance to the success of diabetes care,” said senior author Andrew Karter, PhD, principal investigator of the DISTANCE Study and research scientist at the Kaiser Permanente Division of Research.

“Our studies point out the need for quality improvement efforts in diabetes care to reduce health disparities associated with language, in addition to ethnicity,” Karter said. “As the U.S. becomes linguistically more diverse, and as the prevalence of diabetes continues to rise, it is increasingly important to understand how language barriers may prevent patients from getting the best possible care.”

While this study does not prove that language barriers cause the disparities in diabetes control, it suggests that having a doctor who speaks the patient’s language is important, the authors said. They recommended that health plans systematically offer diabetes patients a health care provider who speaks the patient’s language, whenever possible.

Data collection and analyses for this study was conducted by the DISTANCE study, which enrolled 20,000 patients from the Kaiser Permanente Northern California Diabetes Registry.  The overarching aim of DISTANCE is to investigate ethnic and educational disparities in diabetes-related behaviors, processes of care and health outcomes.

Co-authors include Dean Schillinger, MD, of the UCSF Center for Vulnerable Populations; Yael Schenker, MD, and Victoria Salgado, MD, from the UCSF Division of General Internal Medicine at San Francisco General Hospital; Nancy E. Adler, PhD from the UCSF Center for Health and Community; and Margaret Warton, MPH, Howard H. Moffet, MPH, and Ameena Ahmed, MD, from the Division of Research, Kaiser Permanente Northern California.

The DISTANCE study and research team were funded by the National Institute of Diabetes, Digestive and Kidney Diseases; the National Institute of Child Health and Human Development; and the National Center for Research Resources. Sarkar is supported by the Agency for Healthcare Research and Quality. Schillinger is supported by a grant from Agency for Healthcare Research and Quality and an NIH Clinical and Translational Science Award.

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