Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?

BACKGROUND: Patient-physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient-physician communication. OBJECTIVE: To examine the association of patient race/ethnicity and language and patient-physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system. DESIGN: We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient and physician race/ethnicity and language on adherence to CVD medications, after controlling for patient and physician characteristics. RESULTS: Ten percent of African American, 11 % of Hispanic, 63% of Asian, and 47% of white patients had same race/ethnicity physicians. 24% of Spanish-speaking patients were linguistically concordant with their physicians. African American (46%), Hispanic (49%) and Asian (52%) patients were significantly less likely than white patients (58%) to be in good adherence to all of their CVD medications (p<0.001). Spanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p<0.001). Race concordance for African American patients was associated with adherence to all their CVD medications (53% vs. 50%, p<0.05). Language concordance was associated with medication adherence for Spanish-speaking patients (51% vs. 45%, p<0.05). CONCLUSION: Increasing opportunities for patient-physician race/ethnicity and language concordance may improve medication adherence for African American and Spanish-speaking patients, though a similar effect was not observed for Asian patients or English-proficient Hispanic patients.

The predictors of patient-physician race and ethnic concordance: a medical facility fixed-effects approach.

OBJECTIVE: To examine the predictors of patient-physician race/ethnicity concordance among diabetes patients in an integrated delivery system. DATA SOURCE: Kaiser Permanente's Northern California Diabetes Registry of 2005. STUDY DESIGN: Logistic regression predicted concordance for each racial/ethnic group. Availability of a concordant physician, whether a patient chose their physician, and patient language were main explanatory variables. DATA COLLECTION/EXTRACTION METHODS: The study population consisted of 109,745 patients and 1,750 physicians. PRINCIPAL FINDINGS: Patients who chose their physicians were more likely to have a same race/ethnicity physician with OR of 2.2 (95 percent CI 1.74-2.82) for African American patients, 1.71 (95 percent CI 1.44-2.04) for Hispanic patients, 1.11 (95 percent CI 1.04-1.18) for white patients, and 1.38 (95 percent CI 1.23, 1.55) for Asian patients. Availability of a same race/ethnicity physician was also a predictor of concordance for African American patients (OR 2.7; 95 percent CI 2.45-2.98) and marginally significant for Hispanic patients (OR 1.02; 95 percent CI 1.01-1.02), white patients (OR 1.02; 95 percent CI 1.00-1.04), and Asian patients (OR 1.05; 95 percent CI 1.03, 1.07). Limited English language was a strong predictor of concordance for Hispanic patients (OR 4.81; 95 percent CI 4.2-5.51) and Asian patients (OR 9.8; 95 percent CI 7.7, 12.6). CONCLUSION: Patient language, preferences, and the racial composition of the physician workforce predict race/ethnicity concordance.

Patient race/ethnicity and patient-physician race/ethnicity concordance in the management of cardiovascular disease risk factors for patients with diabetes.

OBJECTIVE Patient-physician race/ethnicity concordance can improve care for minority patients. However, its effect on cardiovascular disease (CVD) care and prevention is unknown. We examined associations of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and appropriate modification of treatment in response to high risk factor values (treatment intensification) in a large cohort of diabetic patients. RESEARCH DESIGN AND METHODS The study population included 108,555 adult diabetic patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient race/ethnicity on risk factor control and treatment intensification after adjusting for patient and physician-level characteristics. RESULTS African American patients were less likely than whites to have A1C <8.0% (64 vs. 69%, P < 0.0001), LDL cholesterol <100 mg/dl (40 vs. 47%, P < 0.0001), and systolic blood pressure (SBP) <140 mmHg (70 vs. 78%, P < 0.0001). Hispanic patients were less likely than whites to have A1C <8% (62 vs. 69%, P < 0.0001). African American patients were less likely than whites to have A1C treatment intensification (73 vs. 77%, P < 0.0001; odds ratio [OR] 0.8 [95% CI 0.7-0.9]) but more likely to receive treatment intensification for SBP (78 vs. 71%, P < 0.0001; 1.5 [1.3-1.7]). Hispanic patients were more likely to have LDL cholesterol treatment intensification (47 vs. 45%, P < 0.05; 1.1 [1.0-1.2]). Patient-physician race/ethnicity concordance was not significantly associated with risk factor control or treatment intensification. CONCLUSIONS Patient race/ethnicity is associated with risk factor control and treatment intensification, but patient-physician race/ethnicity concordance was not. Further research should investigate other potential drivers of disparities in CVD care.

The association of patient age with cardiovascular disease risk factor treatment and control in diabetes.

BACKGROUND: While inadequate treatment intensification may contribute to sub-optimal CVD risk factor control in older patients with diabetes, the relationship between patient age and treatment intensification is largely unexplored. OBJECTIVE: To examine differences in treatment intensification and control for blood pressure (BP), lipids and A1c in older vs. younger adults with diabetes. METHODS: A total of 161,697 Kaiser Permanente Northern California adult diabetes patients were stratified by age (<50, 50-64, 65-74 and 75-85) and assessed for control of A1c (<8%), LDL-c (<100 mg/dl) and SBP (<140 mmHg). Probit models assessed the marginal effects of patient age on treatment intensification and control for all three CVD risk factors. RESULTS: Patients aged 50-64 and 65-74 were significantly more likely to receive treatment intensification for elevated SBP than patients under 50 (74% and 76% vs. 71%) and significantly less likely to receive treatment intensification for elevated A1c (73% and 72% vs. 76%), with no differences noted for LDL-c treatment. Older patients had significantly worse SBP control, but better control of A1c and LDL-c. CONCLUSIONS: Both treatment intensification rates and control of BP, A1c and LDL cholesterol control varied somewhat by age, suggesting room for further improvement in treatment intensification and control.

The association of patient-physician gender concordance with cardiovascular disease risk factor control and treatment in diabetes.

BACKGROUND: Gender concordance between patients and their physicians is related to prevention screening and other quality indicators. Research suggests female physicians may place greater emphasis on preventive care than male physicians; however, little is known about whether physician gender and patient-physician gender concordance are associated with cardiovascular disease (CVD) risk factor levels and treatment. Our objective was to examine associations between patient gender, physician gender, and their interaction with CVD risk factor control, medication adherence, and treatment intensification in diabetes. METHODS: In this study, 157,458 Kaiser Permanente Northern California adult diabetes patients with a primary care physician (PCP) were assessed for above target levels of hemoglobin A1c (HbA1c) (>or=8%), low-density lipoprotein cholesterol (LDL-C) (>or=100 mg/dL), and systolic blood pressure (SBP>or=130 mm Hg) in 2005. Medication adherence and appropriate CVD treatment intensification were assessed using pharmacy data. Probit models assessed the adjusted marginal effects of patient gender, PCP gender, and their interaction on control, adherence, and intensification. RESULTS: Female patients had lower adjusted rates of LDL-C (46% vs. 55%, p<0.001) and SBP control (52% vs. 60%, p<0.001) than males. Female patients of female PCPs had the highest adjusted rates of HbA1c control of the four patient-physician gender dyads (70% vs. 66%-68%, p<0.05). Male patients were more likely than female patients to receive treatment intensification for high SBP (60% vs. 57%, p<0.001). Female PCPs were more likely than their male counterparts to intensify therapy for hyperlipidemia and hypertension. CONCLUSIONS: Patient and physician gender and gender concordance are modestly associated with CVD risk factor control and treatment in diabetes. Further understanding of these differences could lead to improved CVD outcomes for women.