Primary Language, Income and the Intensification of Anti-glycemic Medications in Managed Care: the (TRIAD) Study

Journal of General Internal Medicine, Dec 2010

BACKGROUND Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity. OBJECTIVE To examine the associations between primary language, income, and medication intensification. DESIGN Cohort study with 18-month follow-up. PARTICIPANTS One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care. MEASUREMENTS Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c ≥ 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan. RESULTS Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes $75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race. CONCLUSIONS Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.

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Primary Language, Income and the Intensification of Anti-glycemic Medications in Managed Care: the (TRIAD) Study

O. Kenrik Duru MS 2 Dori Bilik 1 Laura N. McEwen 1 Arleen F. Brown 2 Andrew J. Karter 0 J. David Curb 6 David G. Marrero 5 Shou-En Lu 4 Michael Rodriguez 3 Carol M. Mangione MSPH 2 0 The Division of Research , Kaiser Permanente, Oakland, CA, USA 1 Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Michigan , Ann Arbor, MI, USA 2 Division of General Internal Medicine/Health Services Research, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, CA, USA 3 Department of Family Medicine, University of California , Los Angeles, Los Angeles, CA, USA 4 Department of Biostatistics, UMDNJ-School of Public Health , Piscataway, NJ, USA 5 Department of Medicine, Indiana University School of Medicine , Indianapolis, IN, USA 6 Department of Geriatric Medicine, John A. Burns School of Medicine, University of Hawaii , Honolulu, HI, USA - BACKGROUND: Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity. OBJECTIVE: To examine the associations between primary language, income, and medication intensification. DESIGN: Cohort study with 18-month follow-up. PARTICIPANTS: One thousand nine hundred and thirtynine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care. MEASUREMENTS: Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan. RESULTS: Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race. CONCLUSIONS: Low-income patients were less likely to receive medication intensification compared to higherincome patients, but primary language (Spanish vs. English) was not associated with differences in intensifiA diabetes has improved over the last two decades, minorlthough glycemic control among patients with Type 2 ities continue to have elevated hemoglobin A1c (A1c) values compared to whites.1 Non-English speaking minorities are at even greater risk of poor control, as Spanish-speaking Latinos with Type 2 diabetes have higher A1c values than Englishspeakers.24 Income has also been associated with glycemic control, as low-income patients typically have higher A1c values than higher-income patients.5 As a result of ongoing poor metabolic control, both Spanish-speaking and lowincome patients with diabetes have disproportionately higher rates of microvascular complications.6,7 Inadequate intensification of anti-glycemic diabetes medications, either because providers never attempt to intensify the medication regimen (clinical inertia)8 or because patients are unwilling to accept a more intensive regimen, potentially explains suboptimal glycemic control. Low-income and/or Spanish-speaking patients may be less likely than higherincome and/or English-speaking patients to begin intensified regimens for a variety of reasons, including poor patientprovider communication, lack of patient trust in the provider and/or the medications, concern about potential side effects, fewer outpatient visits and therefore less frequent opportunities to intensify, or concern about the additional out-of-pocket cost of potential new medications.912 While different intensification rates might explain observed disparities in control, few published studies have examined the association between either primary language or income and the intensification of anti-glycemic medications. A recent paper from the Translating Research into Action for Diabetes (TRIAD) study found a small, non-significant difference in medication intensification by patient income.13 However, the analytic sample for this study was limited to patients who completed a two-year follow-up survey, and patients from the lowest education and income strata were disproportionately excluded. For the current TRIAD analysis, we hypothesized that within a prospective cohort of managed care patients who were not taking insulin and had suboptimal control of their diabetes at baseline (A1c8.0%), Spanish-speakers would be less likely than English-speakers to be taking intensified anti-glycemic medication regimens at follow-up. We defined intensification as the addition of a new medication or an increase i (...truncated)


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O. Kenrik Duru MD, MS, Dori Bilik MBA, Laura N. McEwen PhD, Arleen F. Brown MD, PhD, Andrew J. Karter PhD, J. David Curb MD, David G. Marrero PhD, Shou-En Lu PhD, Michael Rodriguez MD, Carol M. Mangione MD, MSPH. Primary Language, Income and the Intensification of Anti-glycemic Medications in Managed Care: the (TRIAD) Study, Journal of General Internal Medicine, 2010, pp. 505-511, Volume 26, Issue 5, DOI: 10.1007/s11606-010-1588-2