Urmimala Sarkar

Social disparities in internet patient portal use in diabetes: evidence that the digital divide extends beyond access

The authors investigated use of the internet-based patient portal, kp.org, among a well-characterized population of adults with diabetes in Northern California. Among 14,102 diverse patients, 5671 (40%) requested a password for the patient portal. Of these, 4311 (76%) activated their accounts, and 3922 (69%), logged on to the patient portal one or more times; 2990 (53%) participants viewed laboratory results, 2132 (38%) requested medication refills, 2093 (37%) sent email messages, and 835 (15%) made medical appointments. After adjustment for age, gender, race/ethnicity, immigration status, educational attainment, and employment status, compared to non-Hispanic Caucasians, African-Americans and Latinos had higher odds of never logging on (OR 2.6 (2.3 to 2.9); OR 2.3 (1.9 to 2.6)), as did those without an educational degree (OR compared to college graduates, 2.3 (1.9 to 2.7)). Those most at risk for poor diabetes outcomes may fall further behind as health systems increasingly rely on the internet and limit current modes of access and communication.

The Literacy Divide: Health Literacy and the Use of an Internet-Based Patient Portal in an Integrated Health System—Results from the Diabetes Study of Northern California (DISTANCE)

Internet-based patient portals are intended to improve access and quality, and will play an increasingly important role in health care, especially for diabetes and other chronic diseases. Diabetes patients with limited health literacy have worse health outcomes, and limited health literacy may be a barrier to effectively utilizing internet-based health access services. We investigated use of an internet-based patient portal among a well characterized population of adults with diabetes. We estimated health literacy using three validated self-report items. We explored the independent association between health literacy and use of the internet-based patient portal, adjusted for age, gender, race/ethnicity, educational attainment, and income. Among 14,102 participants (28% non-Hispanic White, 14% Latino, 21% African-American, 9% Asian, 12% Filipino, and 17% multiracial or other ethnicity), 6099 (62%) reported some limitation in health literacy, and 5671 (40%) respondents completed registration for the patient portal registration. In adjusted analyses, those with limited health literacy had higher odds of never signing on to the patient portal (OR 1.7, 1.4 to 1.9) compared with those who did not report any health literacy limitation. Even among those with internet access, the relationship between health literacy and patient portal use persisted (OR 1.4, 95% CI 1.2 to 1.8). Diabetes patients reporting limited health literacy were less likely to both access and navigate an internet-based patient portal than those with adequate health literacy. Although the internet has potential to greatly expand the capacity and reach of health care systems, current use patterns suggest that, in the absence of participatory design efforts involving those with limited health literacy, those most at risk for poor diabetes health outcomes will fall further behind if health systems increasingly rely on internet-based services.

Validation of Self-Reported Health Literacy Questions Among Diverse English and Spanish-Speaking Populations

BackgroundLimited health literacy (HL) contributes to poor health outcomes and disparities, and direct measurement is often time-intensive. Self-reported HL questions have not been validated among Spanish-speaking and diverse English-speaking populations.ObjectiveTo evaluate three self-reported questions:1 “How confident are you filling out medical forms?”;2 “How often do you have problems learning about your medical condition because of difficulty understanding written information?”; and3 “How often do you have someone help you read hospital materials?” Answers were based on a 5-point Likert scale.DesignThis was a validation study nested within a trial of diabetes self-management support in the San Francisco Department of Public Health.ParticipantsEnglish and Spanish-speaking adults with type 2 diabetes receiving primary care.MethodsUsing the Test of Functional Health Literacy in Adults (s-TOFHLA) in English and Spanish as the reference, we classified HL as inadequate, marginal, or adequate. We calculated the C-index and test characteristics of the three questions and summative scale compared to the s-TOFHLA and assessed variations in performance by language, race/ethnicity, age, and education.Key ResultsOf 296 participants, 48% were Spanish-speaking; 9% were White, non-Hispanic; 47% had inadequate HL and 12% had marginal HL. Overall, 57% reported being confident with forms “somewhat” or less. The “confident with forms” question performed best for detecting inadequate (C-index = 0.82, (0.77-0.87)) and inadequate plus marginal HL (C index = 0.81, (0.76-0.86); p < 0.01 for differences from other questions), and performed comparably to the summative scale. The “confident with forms” question and scale also performed best across language, race/ethnicity, educational attainment, and age.ConclusionsA single self-reported HL question about confidence with forms and a summative scale of three questions discriminated between Spanish and English speakers with adequate HL and those with inadequate and/or inadequate plus marginal HL. The “confident with forms” question or the summative scale may be useful for estimating HL in clinical research involving Spanish-speaking and English-speaking, chronically-ill, diverse populations.

What patients say about their doctors online: a qualitative content analysis.

ABSTRACTBACKGROUNDDoctor rating websites are a burgeoning trend, yet little is known about their content.OBJECTIVETo explore the content of Internet reviews about primary care physicians.DESIGNQualitative content analysis of 712 online reviews from two rating websites. We purposively sampled reviews of 445 primary care doctors (internists and family practitioners) from four geographically dispersed U.S. urban locations. We report the major themes, and because this is a large sample, the frequencies of domains within our coding scheme.RESULTSMost reviews (63%) were positive, recommending the physician. We found a major distinction between global reviews, “Dr. B is a great doctor.” vs. specific descriptions which included interpersonal manner, “She always listens to what I have to say and answers all my questions.”; technical competence “No matter who she has recommended re: MD specialists, this MD has done everything right.”; and/or systems issues such as appointment and telephone access. Among specific reviews, interpersonal manner “Dr. A is so compassionate.” and technical competence “He is knowledgeable, will research your case before giving you advice.” comments tended to be more positive (69% and 80%, respectively), whereas systems-issues comments “Staff is so-so, less professional than should be…” were more mixed (60% positive, 40% negative).CONCLUSIONSThe majority of Internet reviews of primary care physicians are positive in nature. Our findings reaffirm that the care encounter extends beyond the patient–physician dyad; staff, access, and convenience all affect patient’s reviews of physicians. In addition, negative interpersonal reviews underscore the importance of well-perceived bedside manner for a successful patient–physician interaction.

Self-efficacy and health status in patients with coronary heart disease: findings from the heart and soul study.

Objective: To examine the relationship between cardiac self-efficacy and health status, including symptom burden, physical limitation, quality of life, and overall health among outpatients with stable coronary heart disease (CHD). We hypothesized that lower self-efficacy would predict worse health status, independent of CHD severity and depression. Methods: We performed a cross-sectional study of 1024 outpatients with CHD, who were recruited between 2000 and 2002 for the Heart and Soul Study. We administered a validated measure of cardiac self-efficacy, assessed cardiac function using exercise treadmill testing with stress echocardiography, and measured depressive symptoms using the Patient Health Questionnaire. Health status outcomes (symptom burden, physical limitation, and quality of life) were assessed using the Seattle Angina Questionnaire, and overall health was measured as fair or poor (versus good, very good, or excellent). Results: After adjustment for CHD severity and depressive symptoms, each standard deviation (4.5-point) decrease in self-efficacy score was independently associated with greater symptom burden (adjusted odds ratio (OR) = 2.1, p = .001), greater physical limitation (OR = 1.8, p < .0001), worse quality of life (OR = 1.6, p < .0001), and worse overall health (OR = 1.9, p < .0001). Depressive symptoms and poor treadmill exercise capacity were also associated with poor health status, but left ventricular ejection fraction and ischemia were not. Conclusions: Among patients with CHD, low cardiac self-efficacy is associated with poor health status, independent of CHD severity and depressive symptoms. Further study should examine if self-efficacy constitutes a useful target for cardiovascular disease management interventions. CHD = coronary heart disease; OR = odds ratio; LVEF = left ventricular ejection fraction.

Nonsteroidal Anti-Inflammatory Drug Use Among Persons With Chronic Kidney Disease in the United States

PURPOSE Because avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended for most individuals with chronic kidney disease (CKD), we sought to characterize patterns of NSAID use among persons with CKD in the United States. METHODS A total of 12,065 adult (aged 20 years or older) participants in the cross-sectional National Health and Nutrition Examination Survey (1999–2004) responded to a questionnaire regarding their use of over-the-counter and prescription NSAIDs. NSAIDs (excluding aspirin and acetaminophen) were defined by self-report. CKD was categorized as no CKD, mild CKD (stages 1 and 2; urinary albumin-creatinine ratio of ≥30 mg/g) and moderate to severe CKD (stages 3 and 4; estimated glomerular filtration rate of 15–59 mL/min/1.73 m2). Adjusted prevalence was calculated using multivariable logistic regression with appropriate population-based weighting. RESULTS Current use (nearly every day for 30 days or longer) of any NSAID was reported by 2.5%, 2.5%, and 5.0% of the US population with no, mild, and moderate to severe CKD, respectively; nearly all of the NSAIDs used were available over-the-counter. Among those with moderate to severe CKD who were currently using NSAIDs, 10.2% had a current NSAID prescription and 66.1% had used NSAIDs for 1 year or longer. Among those with CKD, disease awareness was not associated with reduced current NSAID use: (3.8% vs 3.9%, aware vs unaware; P=.979). CONCLUSIONS Physicians and other health care clinicians should be aware of use of NSAIDs among those with CKD in the United States and evaluate NSAID use in their CKD patients.

Adverse drug events in U.S. adult ambulatory medical care.

OBJECTIVE To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings. DATA SOURCE We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys. STUDY DESIGN Secondary data analysis. PRINCIPAL FINDINGS An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]). CONCLUSIONS Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.

Care Partners and Online Patient Portals

Each year, more than 65 million people in the United States (29% to 39% of the population) provide care for a chronically ill, disabled, or elderly family member or friend.1 Such caregivers, who help with both basic life functions and managing medical care, are critical to helping people maintain their health and remain in their communities.2 Many chronically ill and older people also have loved ones who, distinct from caregivers, serve as “care partners.” These care partners do not provide day-to-day care or serve as surrogate decision makers but do help navigate health care—facilitating communication with physicians, discussing complex issues requiring shared decision making, and assisting with challenging self-management tasks. The care partner or partners may include a spouse, parent, friend, or relative who assists with health, perhaps across geographic distance.

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 and Hypoglycemia Among Safety Net Patients With Diabetes

In 2008, 1 in every 7 US households was food insecure, or at risk of going hungry because of an inability to afford food.(1) Food insecurity generally occurs cyclically and episodically, with periods of food adequacy followed by food scarcity; the average food insecure household experiences seven episodes of food scarcity annually.(2) We hypothesized that the cyclic nature of food insecurity, and its associated fluctuations in dietary intake, would predispose patients with diabetes to wide variations in blood glucose levels, including clinically significant hypoglycemia.