title: Impact of language barriers on complications and mortality among immigrants with diabetes: a population-based cohort study.
abstract: OBJECTIVE
  Our objective was to examine the effect of language barriers on the risk of acute and chronic complications of diabetes and on mortality among immigrants.
  
  
  METHODS
  Linked health and immigration databases were used to identify 87,707 adults with diabetes who immigrated to Ontario, Canada, between 1985 and 2005. These individuals were included in our cohort and stratified by language ability at the time of their immigration application. Primary end points included: one or more emergency department visit or hospitalization for 1) hypo- or hyperglycemia, skin and soft tissue infection, or foot ulcer and 2) a cardiovascular event or death between April 1, 2005, and February 29, 2012.
  
  
  RESULTS
  Our cohort was followed up for a median of 6.9 person-years. Immigrants with language barriers were older (mean age, 49 ± 15 vs. 42 ± 13 years; P < 0.001), more likely to have immigrated for family reunification (66% vs. 38%, P < 0.001), had less education (secondary school or less and no education, 82% vs. 53%; P < 0.001), and a higher use of health care (mean visits, 8.6 ± 12.1 vs. 7.8 ± 11.2; P < 0.001). Immigrants with language barriers were not found to have higher adjusted rates of diabetes complications (acute complications: hazard ratio [HR] 0.99, 95% CI 0.93-1.05; cardiovascular events or death: HR 0.95, 95% CI 0.91-0.99). Significant predictors included older age, being unmarried, living in a rural neighborhood, and having less education. Immigrants who were older (≥65 years) and who had arrived through family reunification had a lower risk of cardiovascular events or death (HR 0.88, 95% CI 0.81-0.96).
  
  
  CONCLUSIONS
  In a heterogenous immigrant population with universal insurance, language barriers were not found to increase the risk of diabetes complications. However, their effect may vary based on age at time of landing, education level, marital status, and neighborhood of settlement.
authors.affiliation: University Health Network, Toronto, ON, Canada Mount Sinai Hospital and Samuel Lunenfeld Research Institute of Mount Sinai Hospital, Toronto, ON, Canada karen.okrainec@uhn.ca.
authors.forename: Karen
authors.initials: K
authors.lastname: Okrainec
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada Department of Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Gillian L
authors.initials: GL
authors.lastname: Booth
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
authors.forename: Simon
authors.initials: S
authors.lastname: Hollands
authors.affiliation: Mount Sinai Hospital and Samuel Lunenfeld Research Institute of Mount Sinai Hospital, Toronto, ON, Canada Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Department of Medicine, University of Toronto, Toronto, ON, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
authors.forename: Chaim M
authors.initials: CM
authors.lastname: Bell
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D003144:Communication Barriers; D048909:Diabetes Complications / Q000208:ethnology* / Q000401:mortality; D003922:Diabetes Mellitus, Type 1 / Q000208:ethnology* / Q000401:mortality; D003924:Diabetes Mellitus, Type 2 / Q000208:ethnology* / Q000401:mortality; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D004641:Emigration and Immigration; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D006943:Hyperglycemia / Q000208:ethnology; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000208:ethnology / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D012423:Rural Health; D055815:Young Adult