Rachel O’Conor

Disparities in registration and use of an online patient portal among older adults: findings from the LitCog cohort

Objective To document disparities in registration and use of an online patient portal among older adults. Materials and methods Data from 534 older adults were linked with information from the Northwestern Medicine Electronic Data Warehouse on patient portal registration and use of functions (secure messaging, prescription reauthorizations, checking test results, and monitoring vital statistics). Age, gender, race, education, self-reported chronic conditions, and the Newest Vital Sign health literacy measure were available from cohort data. Results Most patients (93.4%) had a patient portal access code generated for them, and among these 57.5% registered their accounts. In multivariable analyses, White patients (P < .001) and college graduates were more likely to have registered their patient portal (P = .015). Patients with marginal (P = .034) or adequate (P < .001) health literacy were also more likely to have registered their patient portal. Among those registering their accounts, most had messaged their physician (90%), checked a test result (96%), and ordered a reauthorization (55%), but few monitored their vital statistics (11%). Adequate health literacy patients were more likely to have used the messaging function (P = .003) and White patients were more likely to have accessed test results (P = .004). Higher education was consistently associated with prescription reauthorization requests (all P < .05). Discussion Among older American adults, there are stark health literacy, educational, and racial disparities in the registration, and subsequent use of an online patient portal. These population sub-group differences may exacerbate existing health disparities. Conclusions If patient portals are implemented, intervention strategies are needed to monitor and reduce disparities in their use.

The association of health literacy with illness and medication beliefs among patients with chronic obstructive pulmonary disease

Background Low health literacy is associated with low adherence to self-management in many chronic diseases. Additionally, health beliefs are thought to be determinants of self-management behaviors. In this study we sought to determine the association, if any, of health literacy and health beliefs among elderly individuals with COPD. Methods We enrolled a cohort of patients with COPD from two academic urban settings in New York, NY and Chicago, IL. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Using the framework of the Self-Regulation Model, illness and medication beliefs were measured with the Brief Illness Perception Questionnaire (B-IPQ) and Beliefs about Medications Questionnaire (BMQ). Unadjusted analyses, with corresponding Cohen’s d effect sizes, and multiple logistic regression were used to assess the relationships between HL and illness and medication beliefs. Results We enrolled 235 participants, 29% of whom had low health literacy. Patients with low health literacy were more likely to belong to a racial minority group (p<0.001), not be married (p = 0.006), and to have lower income (p<0.001) or education (p<0.001). In unadjusted analyses, patients with low health literacy were less likely to believe they will always have COPD (p = 0.003, Cohen’s d = 0.42), and were more likely to be concerned about their illness ((p = 0.04, Cohen’s d = 0.17). In analyses adjusted for sociodemographic factors and other health beliefs, patients with low health literacy were less likely to believe that they will always have COPD (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.65–0.94). In addition, the association of low health literacy with expressed concern about medications remained significant (OR: 1.20, 95% CI: 1.05–1.37) though the association of low health literacy with belief in the necessity of medications was no longer significant (OR: 0.92, 95% CI: 0.82–1.04). Conclusions In this cohort of urban individuals with COPD, low health literacy was prevalent, and associated with illness beliefs that predict decreased adherence. Our results suggest that targeted strategies to address low health literacy and related illness and medications beliefs might improve COPD medication adherence and other self-management behaviors.

Chronic Obstructive Pulmonary Disease Illness and Medication Beliefs are Associated with Medication Adherence

Abstract Almost half of patients with COPD do not adhere to their medications. Illness and medication beliefs are important determinants of adherence in other chronic diseases. Using the framework of the Common Sense Model of Self-Regulation (CSM), we determined associations between potentially modifiable beliefs and adherence to COPD medications in a cohort of English- and Spanish-speaking adults with COPD from New York and Chicago. Medication adherence was assessed using the Medication Adherence Report Scale. Illness and medication beliefs along CSM domains were evaluated using the Brief Illness Perception Questionnaire (B-IPQ) and the Beliefs about Medications Questionnaire (BMQ). Unadjusted analysis (with Cohens d effect sizes) and multiple logistic regression were used to assess the relationship between illness and medication beliefs with adherence. The study included 188 participants (47% Black, 13% Hispanics); 109 (58%) were non-adherent. Non-adherent participants were younger (p < 0.001), more likely to be Black or Hispanic (p = 0.001), to have reported low income (p = 0.02), and had fewer years of formal education (p = 0.002). In unadjusted comparisons, non-adherent participants reported being more concerned about their COPD (p = 0.011; Cohens d = 0.43), more emotionally affected by the disease (p = 0.001; Cohens d = 0.54), and had greater concerns about COPD medications (p < 0.001, Cohens d = 0.81). In adjusted analyses, concerns about COPD medications independently predicted non-adherence (odds ratio: 0.52, 95% confidence interval: 0.36–0.75). In this cohort of urban minority adults, concerns about medications were associated with non-adherence. Future work should explore interventions to influence patient adherence by addressing concerns about the safety profile and long-term effects of COPD medications.

ABCs or 123s? The independent contributions of literacy and numeracy skills on health task performance among older adults

Highlights • Literacy and numeracy are highly correlated.• In multivariable analysis, literacy and numeracy were independent predictors of health task performance.• Literacy and numeracy are complementary skills and both are important for health self-management.

Characteristics of outpatient clinical summaries in the United States

In the United States, federal regulations require that outpatient practices provide a clinical summary to ensure that patients understand what transpired during their appointment and what to do before the next visit. To determine whether clinical summaries are appropriately designed to achieve these objectives, we examined their content and formatting and their usability. We obtained a convenience sample of clinical summaries from 13 diverse practices across the U.S. and assessed their characteristics using validated measures. We also interviewed key informants at these practices to assess their views of the documents. The summaries were generated by seven different electronic health record platforms. They had small font sizes (median, 10 point) and high reading grade levels (median, 10). Suitability, measured with the Suitability Assessment of Materials was low (median score, 61%) and understandability and actionability, measured with the Patient Education Materials Assessment Test, were fair to moderate (65% and 78%, respectively). Content and order of content were inconsistent across the summaries. Among physicians, 46% found the summaries helpful for clarifying medications while 38% found them helpful for conveying follow-up information. Results suggest that clinical summaries in the U.S. may often be suboptimally designed for communicating important information with patients. A patient-centered approach to designing them is warranted.

Increasing screening mammography among predominantly Spanish speakers at a federally qualified health center using a brief previsit video

OBJECTIVE Assess the impact of a 5min video on screening mammogram referrals and completion. METHODS We recruited women ages 40 years or older without a current mammogram at a federally qualified community health center (FQHC). Women were assigned to the intervention or usual care. Immediately prior to their appointments, women in the intervention group viewed a brief video that included a demonstration of how patients may request a mammogram referral. All women completed a pre- and post-visit telephone survey about knowledge of breast cancer screening and patient activation. RESULTS Mean age was 52 years, 50% had less than a high school education and 75% preferred Spanish. The proportion of mammogram referrals in the intervention group was significantly higher than the control group, 37% vs. 15%, respectively (p<0.01). Similarly, the intervention group had a higher proportion of completed mammograms, 33% vs. 13% (p<0.02). There were no differences in breast cancer knowledge or patient activation between the intervention and control groups. CONCLUSIONS A brief, pre-visit video significantly increased screening mammography referrals and completion in this mostly Spanish-speaking FQHC population. PRACTICE IMPLICATIONS Our intervention demonstrates the effectiveness of a brief-video intervention in a population with low education and low English language proficiency.

Development and Validation of the Consumer Health Activation Index

Background. Although there has been increasing interest in patient engagement, few measures are publicly available and suitable for patients with limited health literacy. Objective. We sought to develop a Consumer Health Activation Index (CHAI) for use among diverse patients. Methods. Expert opinion, a systematic literature review, focus groups, and cognitive interviews with patients were used to create and revise a potential set of items. Psychometric testing guided by item response theory was then conducted among 301 English-speaking, community-dwelling adults. This included differential item functioning analyses to evaluate item performance across participant health literacy levels. To determine construct validity, CHAI scores were compared to scales measuring similar personality constructs. Associations between the CHAI and physical and mental health established predictive validity. A second study among 9,478 adults was used to confirm CHAI associations with health outcomes. Results. Exploratory factor analyses revealed a single-factor solution with a 10-item scale. The CHAI showed good internal consistency (alpha = 0.81) and moderate test–retest reliability (ICC = 0.53). Reading grade level was found to be at the 6th grade. Moderate to strong correlations were found with similar constructs (Multidimensional Health Locus of Control, r = 0.38, P < 0.001; Conscientiousness, r = 0.41, P < 0.001). Predictive validity was demonstrated through associations with functional health status measures (depression, r = −0.28, P < 0.001; anxiety, r = −0.22, P < 0.001; and physical functioning, r = 0.22, P < 0.001). In the validation sample, the CHAI was significantly associated with self-reported physical and mental health (r = 0.31 and 0.32 respectively; both P < 0.001). Conclusions. The CHAI appears to be a valid, reliable, and easily administered tool that can be used to assess health activation among adults, including those with limited health literacy. Future studies should test the tool in actual use and explore further applications.

Mild Visual Impairment and Its Impact on Self-Care Among Older Adults

Objective: To determine the prevalence of mild visual impairment (MVI) among urban older adults in primary care settings, and ascertain whether MVI was a risk factor for inadequate performance on self-care health tasks. Method: We used data from a cohort of 900 older adults recruited from primary care clinics. Self-management skills were assessed using the Comprehensive Health Activities Scale, and vision with corrective lenses was assessed with the Snellen. We modeled visual acuity predicting health task performance with linear regression. Results: Normal vision was associated with better overall health task performance (p = .004). Individuals with normal vision were more likely to recall health information conveyed via multimedia (p = .02) and during a spoken encounter (p = .04), and were more accurate in dosing multi-drug regimens (p = .05). Discussion: MVI may challenge the performance of self-care behaviors. Health care systems and clinicians should consider even subtle detriments in visual acuity when designing health information, materials, and devices.

Diminished Cognitive Function Among Chronic Obstructive Pulmonary Disease Patients During Periods of Acute Illness Exacerbation

Dear Editor, Adults with chronic obstructive pulmonary disease (COPD) are known to experience more rapid declines in cognitive function over time than adults without the disease (1). It is not known, however, how their cognitive functioning changes in the context of acute COPD exacerbations, when they may be exposed to conditions that often disrupt cognitive processes, like hypoxemia, high dose steroids, and altered sleep-wake cycles. In this study, we evaluated change in cognitive function during and after COPD-related hospitalizations.