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)