Disparities in Reporting a History of Cardiovascular Disease Among Adults With Limited English Proficiency and Angina

Key Points Question Is limited English proficiency (LEP) associated with not reporting a history of cardiovascular disease (CVD) among those with anginal symptoms? Findings In this cross-sectional analysis of 583 participants in the National Health and Nutrition Examination Survey who had anginal symptoms, participants with LEP had significantly greater odds of not reporting a history of CVD compared with those without LEP in multivariable-adjusted models. Meaning These findings highlight the importance of reducing disparities in treatment and CVD prevention for individuals with LEP.


Introduction
The overwhelming majority of US residents speak English, but approximately 9% of the US population is classified as having limited English proficiency (LEP). 1 People with LEP experience significant health care barriers. 2- 4 Language barriers have been associated with increased hospital length of stay, 5,6 hospital readmissions, 7,8 and limited understanding of appointment type and postdischarge medication use. 9 In the international setting, the consequences of language barriers have been documented across countries in Europe, Africa, and the Middle East, with findings similar to those detected in the United States. 10 Importantly, LEP and other language barriers are fundamentally detrimental to health literacy, further associated with poor health, adverse outcomes, and limited communication between the patient and health care practitioner. 8,11,12 In a population-based sample, respondents with both LEP and low health literacy reported the highest prevalence of poor health when compared with those described as being non-LEP or having adequate health literacy. 11 Even with the use of interpreters, individuals with LEP have reported difficulty understanding interpreters and feeling that interpreters omitted significant information during interactions. 13 A recent systematic review investigating hospital-based interventions to improve communication, quality of care, and health outcomes for individuals with LEP concluded that more research is needed to address the gaps in language services and communication quality provided to individuals with LEP. 14 Other factors also contribute to limited health care access and poor health outcomes for individuals with LEP. Individuals with LEP have reported racial and linguistic discrimination in the health care setting and avoid care as a result of these experiences. 2 Patients without legal immigration status have hesitated to receive emergency medical attention. Additionally, health care practitioners may provide interventions and care that may be culturally insensitive or inappropriate. 2 Suggestions to change certain diet or lifestyle behaviors may degrade the patient-practitioner relationship. Being sensitive to a patient's background, culture, and experience is critical to providing high quality patient-centered care and reducing poor health outcomes. 12 Addressing gaps in research for individuals with LEP presents several challenges given that few recurring national health surveys actively enroll LEP participants. The National Health and Nutrition Examination Survey (NHANES) is one of the few national research programs that facilitates studying individuals with LEP in the US population. NHANES is administered primarily in English and Spanish and, if needed, provides interpreters to assist its completion in other languages. 15 The association between LEP and cardiovascular disease (CVD) outcomes has had limited investigation. A prior study used NHANES data to document the association of uncontrolled hypertension in individuals with LEP compared with those without LEP. 16 NHANES data provide additional opportunities to assess how LEP may be associated with disparities between symptoms of CVD and self-reported history. Angina is widely identified as a symptom of heart disease and is critical in the recognition and prevention of CVD. [17][18][19] For individuals with LEP and a history of CVD, recognition and accurate reporting of their history may affect evaluation and secondary prevention.
We therefore assessed the association between LEP and self-reported history of CVD among NHANES participants with anginal symptoms. We hypothesized that among NHANES participants with angina, people with LEP would be more likely not to report a history of CVD than those without LEP.

Study Sample and Definitions
in-home interview, and a mobile examination center examination. 15 Further publications describing the survey methods and operations are available on the NHANES website. 20 Informed consent was obtained from all participants, and the NCHS Research Ethics Review Board approved NHANES to conduct the surveys and examinations. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.
We included publicly available data from five 2-year NHANES cycles spanning 2007 to 2016. A complete list of NHANES files used for analyses are detailed in the eAppendix in the Supplement. LEP was defined as taking the interview instrument in a language other than English or the use of an interpreter during the interview. The NHANES database includes a notation of whether interpretation services were used for each participant. 21 Self-reported CVD was defined by a participant indicating a history of heart failure, coronary heart disease, angina and/or angina pectoris, or myocardial infarction.
Overall, 19 320 survey participants aged 40 years or older received the cardiovascular health questionnaire and were included in this analysis. The cardiovascular health questionnaire includes the 7-item Rose questionnaire, an inexpensive and reliable instrument that has undergone extensive validation to identify the presence of symptoms consistent with angina and ischemic heart pain. 22 The questionnaire has high specificity (97%) and moderate sensitivity (approximately 83%) to detect angina pectoris, myocardial infarction, and intermittent claudication. 17,22 Additionally, the questionnaire has demonstrated value in detecting coronary heart disease and myocardial infarction in diverse populations. 23-27 Specifically, the Rose questionnaire has been studied in Spanishspeaking populations and was found to be a reliable tool. 27 Definitions for grade of angina are defined in the eAppendix in the Supplement.

Race and ethnicity was classified into Mexican American, non-Hispanic Black, non-Hispanic
White, other Hispanic, and other race (ie, American Indian or Alaskan Native; Native Hawaiian or Pacific Islander; multiple races or ethnicities; or unknown). Dichotomous ethnicity (Hispanic or non-Hispanic) was created for regression analyses. Body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and mean blood pressure over 3 measurements, both obtained at the NHANES standardized examination, were analyzed as continuous variables. Diabetes was defined through self-report, and those with borderline diabetes were classified as not having the condition. We also included health insurance (yes or no), number of health care visits over the past 12 months (0, 1-3, 4-9, and Ն10), ratio of family income to poverty (poverty-income ratio), and educational attainment (Յhigh school or >high school equivalent). The poverty-income ratio was calculated by NHANES and uses the Department of Health and Human Services poverty guidelines specific to family size and geographic location. 21

Statistical Analysis
Categorical variables are presented as crude frequencies and weighted proportions, and continuous variables are expressed as means with the associated SD or 95% CI. We examined the characteristics of the entire NHANES cohort that completed the cardiovascular health questionnaire and the subset that screened positive for angina on the Rose questionnaire, stratified by LEP status. χ 2 tests and t tests were performed to assess differences in the characteristics between the non-LEP and LEP groups for categorical and continuous variables, respectively. Multicollinearity between LEP and race and ethnicity were assessed using χ 2 tests. The proportion of participants self-reporting CVD who screened positive on the Rose questionnaire for each survey year was plotted by LEP status, and an unadjusted linear regression model was used to estimate the linear relationships with 95% CIs using Prism version 8.4.3 (GraphPad).
We used multivariable logistic regression to associate LEP status with whether participants did not report a history of CVD. Missing data were incorporated into each analysis and considered not missing completely at random. 28 This was performed by adding the NOMCAR option to all models in SAS version 9.4 (SAS Institute). Four models were constructed with the following independent variables: model 1 (LEP; age [per 10 years], sex, race and ethnicity), model 2 (model 1 as well as BMI Sensitivity analyses were conducted to (1) determine the association between race and ethnicity and self-reported CVD without LEP in regression models; (2) model self-reported myocardial infarction, rather than all CVD conditions, given that the Rose questionnaire has particularly high sensitivity for myocardial infarction; and (3)   In sensitivity analyses, the detailed race and ethnicity variable was included as an independent variable (without LEP) using 3 similar models; no significant association was detected between race and ethnicity and reported CVD (eTable 1 in the Supplement in the Supplement detail the sensitivity analysis for diabetes; small but statistically significant differences were found in the agreement between self-reported diabetes status and fasting plasma glucose levels by LEP status.

Discussion
In this nationally representative study incorporating 5 cycles of NHANES participants, we found that individuals with LEP were 2.8-fold more likely not to report having been diagnosed with CVD compared with those without LEP (odds ratio, 2.77; 95% CI, 1.38-5.55; P = .005). This association was independent of age, sex, BMI, diastolic blood pressure, and diabetes status. Our findings suggest that the rate of self-reported CVD is low across all NHANES participants reporting anginal symptoms.
Indeed, two-thirds of those who screened positive on the Rose questionnaire did not report a CVD diagnosis. Furthermore, our findings exhibit that this discordance-reporting anginal symptoms without having been diagnosed with CVD-is much more likely for individuals with LEP. In the full NHANES cohort, positive screening rates on the Rose questionnaire were similar across LEP status, suggesting a similar underlying prevalence of CVD. Similarly, grade of angina was very similar by LEP status, suggesting severity of symptoms and the likelihood of CVD (diagnosed or undiagnosed) was also similar. To be sure, with a proper evaluation, a person with positive Rose questionnaire screening could certainly be found to have or not have a cardiac diagnosis. However, it is important to note that the overall frequency of self-reported CVD (37.2%) was far lower than what would be anticipated given the sensitivity and specificity of the Rose questionnaire (eg, 81% and 97% for angina pectoris, respectively). 17 This presents a major gap in care; many people have symptoms indicative of CVD but have not received a diagnosis. Accordingly, significant improvements are needed in screening and evaluation for CVD in the general US population.
Among the 64.2 million people who speak a language other than English, 25.7 million, or 8.5% of the entire population aged 5 years and older, are estimated to have LEP. 31 Federal regulations, such  as Title VI of the Civil Rights Act, are in place to protect individuals with LEP from discrimination and receipt of substandard health care. However, data indicate that some hospitals do not provide sufficient language services to patients with LEP and are thereby not compliant with federal law. 32 Our findings are consistent with a previous study that analyzed English proficiency and postdischarge understanding of follow-up appointments and medication use. 9 Our results are also congruent with data from the Hispanic Community Health Study/Study of Latinos, which identified that not speaking English as a primary language was strongly associated with suboptimal care, including not receiving guideline-directed therapies. 33 The greater proportion of participants with LEP not reporting previous CVD diagnoses in our study is likely attributable to multiple factors. NHANES participants may have received a previous diagnosis from their health care practitioner but did not understand or were not able to recall this information during the study examination. Miscommunication of this kind could certainly be more Another pertinent finding is that women with a positive Rose questionnaire were 2.6 times more likely not to report CVD compared to men with a positive Rose questionnaire (odds ratio, 2.63; 95% CI, 1.57-4.40). This finding suggests that diagnostic screening and appropriate evaluations for CVD may need to be increased in women. These data potentially suggest that practitioners may not appreciate or otherwise disregard symptoms of CVD by female vs male patients. This is consistent with prior reports of symptoms of angina in women but low rates of diagnosed CVD. 18,34 Through the national community-based sampling of NHANES, we were able to determine associations generalizable to the entire population of individuals identified as having LEP in the United States and not only the segment of those with LEP in contact with the health care system. Our study identifies a disparity in cardiovascular health for people with LEP. Gaps in screening, diagnosis, communication regarding CVD, and access to services can all lead to poor outcomes. Health care institutions should identify systems-level barriers to care for patients who do not communicate in the dominant language. By incorporating patient-centered practices, such as screening for and assessing risk for CVD in an individual's preferred language, more patients may benefit from the equitable provision of guideline-directed therapies. Further research is needed to understand the burden of CVD in the US population with LEP and to assess for disparities in evaluation, treatment, and understanding of these conditions.

Limitations
We acknowledge that our study has some important limitations. NHANES uses self-reporting of diagnoses. As such, the diagnoses used here may be subject to different types of response bias and result in misclassification of our outcome variable. However, the ability to recall and understand diagnoses was a primary interest of this study. Verification and adjudication of self-reported diagnosis is not possible when using NHANES data. Second, the number of participants with LEP was relatively small, such that our analyses were underpowered to determine reliable estimates in certain tabulations where respondent counts were excessively low (eg, by race and LEP). Our definition for LEP may lead to misclassification, as participants may have chosen to take the interview in a language other than English or use an interpreter when they could have completed the survey in English.