Courtney R. Lyles

Association of Depression With Increased Risk of Dementia in Patients With Type 2 Diabetes The Diabetes and Aging Study

CONTEXT Although depression is a risk factor for dementia in the general population, its association with dementia among patients with diabetes mellitus has not been well studied. OBJECTIVE To determine whether comorbid depression in patients with type 2 diabetes increases the risk of development of dementia. DESIGN The Diabetes and Aging Study was a cohort investigation that surveyed a racially/ethnically stratified random sample of patients with type 2 diabetes. SETTING A large, integrated, nonprofit managed care setting in Northern California. PARTICIPANTS A sample of 19,239 diabetes registry members 30 to 75 years of age. MAIN OUTCOME MEASURES The Patient Health Questionnaire 8, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses of depression, and/or antidepressant prescriptions in the 12 months prior to baseline were used to identify prevalent cases of depression. Clinically recognized dementia was identified among subjects with no prior ICD-9 Clinical Modification (ICD-9-CM) diagnoses of dementia. To exclude the possibility that depression was a prodrome of dementia, dementia diagnoses were only based on ICD-9-CM diagnoses identified in years 3 to 5 postbaseline. The risk of dementia for patients with depression and diabetes relative to patients with diabetes alone was estimated using Cox proportional hazard regression models that adjusted for sociodemographic, clinical, and health risk factors and health use. RESULTS During the 3- to 5-year period, 80 of 3766 patients (2.1%) with comorbid depression and diabetes (incidence rate of 5.5 per 1000 person-years) vs 158 of 15,473 patients (1.0%) with diabetes alone (incidence rate of 2.6 per 1000 person-years) had 1 or more ICD-9-CM diagnoses of dementia. Patients with comorbid depression had a 100% increased risk of dementia during the 3 to 5 years postbaseline (adjusted hazard ratio, 2.02; 95% confidence interval, 1.73-2.35). CONCLUSION Depression in patients with diabetes was associated with a substantively increased risk for development of dementia compared with those with diabetes alone.

Qualitative evaluation of a mobile phone and web-based collaborative care intervention for patients with type 2 diabetes.

BACKGROUND Drawing on previous web-based diabetes management programs based on the Chronic Care Model, we expanded an intervention to include care management through mobile phones and a game console web browser. METHODS The pilot intervention enrolled eight diabetes patients from the University of Washington in Seattle into a collaborative care program: connecting them to a care provider specializing in diabetes, providing access to their full electronic medical record, allowing wireless glucose uploads and e-mail with providers, and connecting them to the programs web services through a game system. To evaluate the study, we conducted qualitative thematic analysis of semistructured interviews. RESULTS Participants expressed frustrations with using the cell phones and the game system in their everyday lives, but liked the wireless system for collaborating with a provider on uploaded glucoses and receiving automatic feedback on their blood sugar trends. A majority of participants also expressed that their participation in the trial increased their health awareness. DISCUSSION Mobile communication technologies showed promise within a web-based collaborative care program for type 2 diabetes. Future intervention design should focus on integrating easy-to-use applications within mobile technologies already familiar to patients and ensure the system allows for sufficient collaboration with a care provider.

Limitations in health care access and utilization among long-term survivors of adolescent and young adult cancer.

Health care outcomes for long‐term survivors of adolescent and young adult (AYA) cancer were compared with young adults without a cancer history, using the 2009 Behavioral Risk Factor Surveillance System data.

Use of the Refill Function through an Online Patient Portal Is Associated with Improved Adherence to Statins in an Integrated Health System

Background:Online patient portals are being widely implemented, but their impact on health behaviors are not well-studied. Objective:To determine whether statin adherence improved after initiating use of the portal refill function. Research Design:Observational cohort study within an integrated health care delivery system. Subjects:Diabetic patients on statins who had registered for online portal access by 2010. A total of 8705 subjects initiated the online refill function use within the study window, including “exclusive” and “occasional” users (ie, requesting all vs. some refills online, respectively). Using risk-set sampling, we temporally matched 9055 reference group patients who never used online refills. Measures:We calculated statin adherence before and after refill function initiation, assessed as percent time without medications (nonadherence defined as a gap of >20%). Secondary outcome was dyslipidemia [low-density lipoprotein (LDL)≥100]. Difference-in-differences regression models estimated pre-post changes in nonadherence and dyslipidemia, comparing refill function users to the reference group and adjusting for age, sex, race/ethnicity, medications, frequency of portal use, and outpatient visits. Results:In unadjusted examinations, nonadherence decreased only among patients initiating occasional or exclusive use of the refill function (26%–24% and 22%–15%, respectively). In adjusted models, nonadherence declined by an absolute 6% (95% confidence interval, 4%–7%) among exclusive users, without significant changes among occasional users. Similar LDL decreases were also seen among exclusive users. Conclusions:Compared with portal users who did not refill medications online, adherence to statin medications and LDL levels improved among diabetic patients who initiated and exclusively used the patient portal for refills, suggesting that wider adoption of online refills may improve adherence.

Food Insecurity in Relation to Changes in Hemoglobin A1c, Self-Efficacy, and Fruit/Vegetable Intake During a Diabetes Educational Intervention

OBJECTIVE Food insecurity is hypothesized to make diabetes self-management more difficult. We conducted a longitudinal assessment of food insecurity with several diabetes self-care measures. RESEARCH DESIGN AND METHODS We conducted a secondary, observational analysis of 665 low-income patients with diabetes, all of whom received self-management support as part of a larger diabetes educational intervention. We analyzed baseline food insecurity (measured by the U.S. Department of Agriculture Food Security module) in relation to changes in hemoglobin A1c (HbA1c) as well as self-reported diabetes self-efficacy and daily fruit and vegetable intake. We examined longitudinal differences using generalized estimating equation linear regression models, controlling for time, age, sex, race, income, and intervention arm. RESULTS Overall, 57% of the sample had an income <

Patient race/ethnicity and shared medical record use among diabetes patients.

15,000. Participants who were food insecure (33%) were younger, had less income, and were more likely to be unemployed compared with participants who were food secure. At baseline, those who were food insecure had higher mean HbA1c values (8.4% vs. 8.0%) and lower self-efficacy and fruit and vegetable intake than those who were food secure (all P < 0.05). Compared with food-secure individuals, participants who were food insecure had significantly greater improvements in HbA1c over time (0.38% decrease compared with 0.01% decrease; P value for interaction <0.05) as well as in self-efficacy (P value for interaction <0.01). There was no significant difference in HbA1c by food security status at follow-up. CONCLUSIONS Participants experiencing food insecurity had poorer diabetes-related measures at baseline but made significant improvements in HbA1c and self-efficacy. Low-income patients who were food insecure may be particularly receptive to diabetes self-management support, even if interventions are not explicitly structured to address finances or food security challenges.

Barriers and Facilitators to Online Portal Use Among Patients and Caregivers in a Safety Net Health Care System: A Qualitative Study

Background:Previous studies have documented racial/ethnic differences in patients’ use of websites providing shared electronic medical records between patients and health care professionals. Less is known about whether these are driven by patient-level preferences and/or barriers versus broader provider or system factors. Methods:Cross-sectional study of diabetes patients in an integrated delivery system in 2008–2009. Primary measures were race/ethnicity and shared medical record (SMR) use. Covariates included sociodemographics (age, sex, income, education), health status (comorbidity, diabetes severity), and provider characteristics (encouragement of SMR, secure messaging use, clinic). Results:The majority (62%) of Whites used the SMR, compared with 34% of Blacks, 37% of Asians, and 55% of other race/ethnicity (P<0.001). Most respondents (76%) stated that their provider had encouraged them to use the SMR, with no differences by race/ethnicity. Patients saw primary care providers who used a similar amount of secure messaging in their practices—except Asians, who were less likely to see high-messaging providers. In fully adjusted models, Blacks [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.11–0.30] and Asians (OR, 0.40; 95% CI, 0.20–0.77) were significantly less likely than Whites to use the SMR. When restricted to individuals reporting at least occasional Internet use, this finding remained for Black respondents (OR, 0.25; 95% CI, 0.10–0.63). Conclusions:Among diabetes patients, differences in SMR use by race/ethnicity were not fully explained by differences in age, sex, sociodemographics, health status, or provider factors—particularly for Black patients. There were few racial/ethnic differences in provider encouragement or provider secure messaging use that would have suggested disparities at the provider level.

Association Between Clinician Computer Use and Communication With Patients in Safety-Net Clinics

Background Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online. Objective To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital. Methods We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers. Results We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health monitoring, and improvements in patient-provider communication. Participants with limited health literacy discussed more fundamental barriers to portal use, including challenges with reading and typing, personal experience with online security breaches/viruses, and distrust of potential security measures. Caregivers expressed high interest in portal use to support their roles in interpreting health information, advocating for quality care, and managing health behaviors and medical care. Conclusions Despite concerns about security, difficulty understanding medical information, and satisfaction with current communication processes, respondents generally expressed enthusiasm about portal use. Our findings suggest a strong need for training and support to assist vulnerable patients with portal registration and use, particularly those with limited health literacy. Efforts to encourage portal use among vulnerable patients should directly address health literacy and security/privacy issues and support access for caregivers.

Correlates of Patient-Reported Racial/Ethnic Health Care Discrimination in the Diabetes Study of Northern California (DISTANCE)

Title: Association Between Clinician Computer Use and Communication with Patients in Safety- Net Clinics Neda Ratanawongsa, MD, MPH 1,2 neda.ratanawongsa@ucsf.edu Jennifer L. Barton, MD 3 bartoje@ohsu.edu Courtney R. Lyles, PhD 1,2 courtney.lyles@ucsf.edu Michael Wu, BS 4 MichaelWu0322@gmail.com Edward H. Yelin, PhD, MCP 5,6 ed.yelin@ucsf.edu Diana Martinez, MD 1,2 diana.martinez@ucsf.edu Dean Schillinger, MD 1,2 dean.schillinger@ucsf.edu Division of General Internal Medicine, the University of California, San Francisco (UCSF) UCSF Center for Vulnerable Populations at San Francisco General Hospital Department of Medicine at Oregon Health & Science University and VA Portland Health Care System John Burns School of Medicine, University of Hawaii Division of Rheumatology, University of California, San Francisco Institute for Health Policy Studies, University of California, San Francisco Word count: 600 References: 7 Tables: 2 Corresponding Author: Neda Ratanawongsa, MD, MPH Associate Professor of Medicine, Division of General Internal Medicine UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center 1001 Potrero Avenue, Box 1364 San Francisco CA 94110 Phone: 415-206-3188 Fax: 415-206-5586 neda.ratanawongsa@ucsf.edu Presentations: Preliminary data from this manuscript was presented at the International Conference on Communication in Healthcare, Montreal, Quebec, Canada, September 30, 2013 Acknowledgements: Author Contributions: Dr. Ratanawongsa had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ratanawongsa, Yelin, Schillinger. Acquisition, analysis, or interpretation of data: Ratanawongsa, Barton, Lyles, Wu, Martinez. Drafting of the manuscript: Ratanawongsa, Yelin. Critical revision of the manuscript for important intellectual content: Barton, Lyles,Wu, Yelin, Martinez, Schillinger. Statistical analysis: Ratanawongsa, Yelin. Obtained funding: Ratanawongsa, Schillinger. Administrative, technical, or material support: Barton, Lyles,Wu, Martinez,

Getting a technology-based diabetes intervention ready for prime time: a review of usability testing studies.

Objectives. We examined possible determinants of self-reported health care discrimination.Methods. We examined survey data from the Diabetes Study of Northern California (DISTANCE), a race-stratified sample of Kaiser diabetes patients. Respondents reported perceived discrimination, and regression models examined socioeconomic, acculturative, and psychosocial correlates.Results. Subjects (n = 17,795) included 20% Blacks, 23% Latinos, 13% East Asians, 11% Filipinos, and 27% Whites. Three percent and 20% reported health care and general discrimination. Health care discrimination was more frequently reported by minorities (ORs ranging from 2.0 to 2.9 compared with Whites) and those with poorer health literacy (OR51.10, 95% CI: 1.04–1.16), limited English proficiency (OR = 1.91, 95% CI: 1.32–2.78), and depression (OR = 1.53, 95% CI: 1.10–2.13). Conclusions. In addition to race/ethnicity, health literacy and English proficiency may be bases of discrimination. Evaluation is needed to determine whether patients are treated differently or more apt to perceive discrimination, and whether depression fosters and/or follows perceived discrimination.