Use of Complementary Health Approaches Among Diverse Primary Care Patients with Type 2 Diabetes and Association with Cardiometabolic Outcomes: From the SF Bay Collaborative Research Network (SF Bay CRN).

PURPOSE: To describe use of complementary health approaches (CHAs) among patients with type 2 diabetes, and independent associations between CHA use and Hemoglobin A1c (A1C) and lower-density lipoprotein (LDL) cholesterol. METHODS: Participants were enrolled onto the SMARTSteps Program, a diabetes self-management support program conducted between 2009 and 2013 in San Francisco. At the 6-month interview, CHA use in the prior 30 days was estimated using a 12-item validated instrument. Demographic and diabetes-related measures A1C were assessed at baseline and 6-month followup. AIC and LDL values were ascertained from chart review over the study period. Medication adherence was measured using pharmacy claims data at 6 and 12 months. RESULTS: Patients (n = 278) completed 6-month interviews: 74% were women and 71.9% were non-English speaking. Any CHA use was reported by 51.4% overall. CHA modalities included vitamins/nutritional supplements (25.9%), spirituality/prayer (21.2%), natural remedies/herbs (24.5%), massage/acupressure (11.5%), and meditation/yoga/tai chi (10.4%). CHA costs per month were $43.86 (SD = 118.08). Nearly one third reported CHA (30.0%) specifically for their type 2 diabetes. In regression models, elevated A1C (>8.0%) was not significantly associated with overall CHA use (odds ratio [OR] = 1.78; 95% confidence interval [CI], 0.7 to 4.52) whereas elevated LDL was (OR = 3.93; 95% CI, 1.57 to 9.81). With medication adherence added in exploratory analysis, these findings were not significant. CONCLUSIONS: CHA use is common among patients with type 2 diabetes and may be associated with poor cardiometabolic control and medication adherence.

Adherence to Newly Prescribed Diabetes Medications Among Insured Latino and White Patients With Diabetes.

Importance: Medication adherence is essential to diabetes care. Patient-physician language barriers may affect medication adherence among Latino individuals. Objective: To determine the association of patient race/ethnicity, preferred language, and physician language concordance with patient adherence to newly prescribed diabetes medications. Design, Setting, and Participants: This observational study was conducted from January 1, 2006, to December 31, 2012, at a large integrated health care delivery system with professional interpreter services. Insured patients with type 2 diabetes, including English-speaking white, English-speaking Latino, or limited English proficiency (LEP) Latino patients with newly prescribed diabetes medication. Exposures: Patient race/ethnicity, preferred language, and physician self-reported Spanish-language fluency. Main Outcomes and Measures: Primary nonadherence (never dispensed), early-stage nonpersistence (dispensed only once), late-stage nonpersistence (received ≥2 dispensings, but discontinued within 24 months), and inadequate overall medication adherence (>20% time without sufficient medication supply during 24 months after initial prescription). Results: Participants included 21 878 white patients, 5755 English-speaking Latino patients, and 3205 LEP Latino patients with a total of 46 131 prescriptions for new diabetes medications. Among LEP Latino patients, 50.2% (n = 1610) had a primary care physician reporting high Spanish fluency. For oral medications, early adherence varied substantially: 1032 LEP Latino patients (32.2%), 1565 English-speaking Latino patients (27.2%), and 4004 white patients (18.3%) were either primary nonadherent or early nonpersistent. Inadequate overall adherence was observed in 1929 LEP Latino patients (60.2%), 2975 English-speaking Latino patients (51.7%), and 8204 white patients (37.5%). For insulin, early-stage nonpersistence was 42.8% among LEP Latino patients (n = 1372), 34.4% among English-speaking Latino patients (n = 1980), and 28.5% among white patients (n = 6235). After adjustment for patient and physician characteristics, LEP Latino patients were more likely to be nonadherent to oral medications and insulin than English-speaking Latino patients (relative risks from 1.11 [95% CI, 1.06-1.15] to 1.17 [95% CI, 1.02-1.34]; P < .05) or white patients (relative risks from 1.36 [95% CI, 1.31-1.41] to 1.49 [95% CI, 1.32-1.69]; P < .05). English-speaking Latino patients were more likely to be nonadherent compared with white patients (relative risks from 1.23 [95% CI, 1.19-1.27] to 1.30 [95% CI, 1.23-1.39]; P < .05). Patient-physician language concordance was not associated with rates of nonadherence among LEP Latinos (relative risks from 0.92 [95% CI, 0.71-1.19] to 1.04 [95% CI, 0.97-1.1]; P > .28). Conclusions and Relevance: Nonadherence to newly prescribed diabetes medications is substantially greater among Latino than white patients, even among English-speaking Latino patients. 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. Interventions beyond access to interpreters or patient-physician language concordance will be required to improve medication adherence among Latino patients with diabetes.

Identifying Spanish Language Competent Physicians: The Diabetes Study of Northern California (DISTANCE).

OBJECTIVES: Language barriers negatively impact health care access and quality for US immigrants. Latinos are the second largest immigrant group and the largest, fastest growing minority. Health care systems need simple, low cost and accurate tools that they can use to identify physicians with Spanish language competence. We sought to address this need by validating a simple and low-cost tool already in use in a major health plan. DESIGN SETTING PARTICIPANTS: A web-based survey conducted in 2012 among physicians caring for patients in a large, integrated health care delivery system. Of the 2,198 survey respondents, 111 were used in additional analysis involving patient report of those physicians' fluency. MAIN OUTCOME MEASURES: We compared health care physicians' responses to a single item, Spanish language self-assessment tool (measuring "medical proficiency") with patient-reported physician language competence, and two validated physician self-assessment tools (measuring "fluency" and "confidence"). RESULTS: Concordance between medical proficiency was moderate with patient reports (weighted Kappa .45), substantial with fluency (weighted Kappa .76), and moderate-to-substantial with confidence (weighted Kappas .53 to .66). CONCLUSIONS: The single-question self-reported medical proficiency tool is a low-cost tool useful for quickly identifying Spanish competent physicians and is potentially suitable for use in clinical settings. A reasonable approach for health systems is to designate only those physicians who self-assess their Spanish medical proficiency as "high" as competent to provide care without an interpreter.

Advances in measuring culturally competent care: a confirmatory factor analysis of CAHPS-CC in a safety-net population.

BACKGROUND: Providing culturally competent care shows promise as a mechanism to reduce health care inequalities. Until the recent development of the Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set (CAHPS-CC), no measures capturing patient-level experiences with culturally competent care have been suitable for broad-scale administration. METHODS: We performed confirmatory factor analysis and internal consistency reliability analysis of CAHPS-CC among patients with type 2 diabetes (n=600) receiving primary care in safety-net clinics. CAHPS-CC domains were also correlated with global physician ratings. RESULTS: A 7-factor model demonstrated satisfactory fit (χ²231=484.34, P<0.0001) with significant factor loadings at P<0.05. Three domains showed excellent reliability-Doctor Communication-Positive Behaviors (α=0.82), Trust (α=0.77), and Doctor Communication-Health Promotion (α=0.72). Four domains showed inadequate reliability either among Spanish speakers or overall (overall reliabilities listed): Doctor Communication-Negative Behaviors (α=0.54), Equitable Treatment (α=0.69), Doctor Communication-Alternative Medicine (α=0.52), and Shared Decision-Making (α=0.51). CAHPS-CC domains were positively and significantly correlated with global physician rating. CONCLUSIONS: Select CAHPS-CC domains are suitable for broad-scale administration among safety-net patients. Those domains may be used to target quality-improvement efforts focused on providing culturally competent care in safety-net settings.