Evaluating Acceptability, Feasibility and Efficacy of a Diabetes Care Support Program Facilitated by Cellular-Enabled Glucose Meters: A Dissertation

Background. Diabetes requires significant disease management, patient-provider communication, and interaction between patients, family members, caregivers, and care teams. Emerging patient-facing technologies, such as cellular-enabled glucose meters, can facilitate additional care support and improve diabetes self-management. This study evaluated patient acceptability, feasibility, and efficacy of a diabetes care support program facilitated by cellular-enabled glucose meters. Methods. A two-phase study approach was taken. Get In Touch – Phase 1 (GIT-1) was a 1-month pilot involving patients with type 1 and type 2 diabetes. Get In Touch – Phase 2 (GIT-2) was a 12-month randomized controlled crossover trial involving patients with poorly-controlled type 2 diabetes. Results from GIT-1 and preliminary results from GIT-2 are presented. Results. GIT-1 participants with type 1 (n=6) and type 2 (n=10) diabetes reported the intervention and cellular-enabled glucose meter were easy to use and useful while identifying potential areas of improvement. GIT-2 participants in both the intervention (n=60) and control (n=60) groups saw significant improvements in treatment satisfaction and A1c change, with intervention participants experiencing slightly greater improvements in each after 6 months (p=0.09 and p=0.16, respectively) compared to control participants. Conclusions. Patients reported favorable acceptability of the intervention. Preliminary results from a randomized trial demonstrated potential of intervention to improve patient-reported and physiological health outcomes. Future studies should evaluate feasibility and efficacy over a longer period of time, with a greater number of participants, and targeting different populations of patients with diabetes. Provider perspectives and changes in provider behavior, clinical work flow, and caregiver burden should also be assessed

Sustained Use of Patient Portal Features and Improvements in Diabetes Physiological Measures

BACKGROUND: Personal health records (PHRs) have the potential to improve patient self-management for chronic conditions such as diabetes. However, evidence is mixed as to whether there is an association between PHR use and improved health outcomes. OBJECTIVE: The aim of this study was to evaluate the association between sustained use of specific patient portal features (Web-based prescription refill and secure messaging-SM) and physiological measures important for the management of type 2 diabetes. METHODS: Using a retrospective cohort design, including Veterans with diabetes registered for the My Health e Vet patient portal who had not yet used the Web-based refill or SM features and who had at least one physiological measure (HbA1c, low-density lipoprotein (LDL) cholesterol, blood pressure) in 2009-2010 (baseline) that was above guideline recommendations (N=111,686), we assessed portal use between 2010 and 2014. We calculated the odds of achieving control of each measure by 2013 to 2014 (follow-up) by years of using each portal feature, adjusting for demographic and clinical characteristics associated with portal use. RESULTS: By 2013 to 2014, 34.13% (38,113/111,686) of the cohort was using Web-based refills, and 15.75% (17,592/111,686) of the cohort was using SM. Users were slightly younger (P \u3c .001), less likely to be eligible for free care based on economic means (P \u3c .001), and more likely to be women (P \u3c .001). In models adjusting for both features, patients with uncontrolled HbA1c at baseline who used SM were significantly more likely than nonusers to achieve glycemic control by follow-up if they used SM for 2 years (odds ratio-OR=1.24, CI: 1.14-1.34) or 3 or more years (OR=1.28, CI: 1.12-1.45). However, there was no significant association between Web-based refill use and glycemic control. Those with uncontrolled blood pressure at baseline who used Web-based refills were significantly more likely than nonusers to achieve control at follow-up with 2 (OR=1.07, CI: 1.01-1.13) or 3 (OR=1.08, CI: 1.02-1.14) more years of Web-based refill use. Both features were significantly associated with improvements in LDL cholesterol levels at follow-up. CONCLUSIONS: Although rates of use of the refill function were higher within the population, sustained SM use had a greater impact on HbA1c. Evaluations of patient portals should consider that individual components may have differential effects on health improvements

What\u27s in a Message? The Impact of Patient-Clinician Email Message Content on Patient Health Outcomes and Healthcare Utilization

Introduction In the upcoming chapters, we present our study findings as three papers ready for submission to peer-reviewed journals. The first paper describes the associations between taxa and the characteristics of the patients and clinic staff who exchange those messages. The second paper explores the associations between those taxa and patients’ healthcare utilization. The third paper presents associations between taxa and patient health outcomes for diabetes and hypertension. We conclude with how the three papers are related and highlight the importance of this research. Across the three papers, we reference a theory-based taxonomy we developed specifically for secure messaging. A number of researchers have created taxonomies to classify secure message content. Although these contained common themes, many were used only once or twice in published research and few classified content generated by clinic staff. We built our taxonomy upon commonly used themes from these existing classification systems. In contrast with other researchers, however, we leveraged theoretical constructs to group taxa and identify the concepts within messages that must be present for logical linkages between message content and patient outcomes. To identify why patients might outreach to clinicians during times of uncertainty, we referenced Mishel’s Uncertainty in Illness Theory (Mishel, 1988, 1999). We leveraged the framework developed by Street, Makoul, Arora, and Epstein (2009) to highlight patient task-oriented requests that might manifest in secure messages (e.g., to support self-care, satisfaction), and clinician-generated content that might support improved patient health outcomes. Our three papers present the first reports using this taxonomy and are the first to explore associations between taxa, patient outcomes, and the senders’ and receivers’ characteristics. We sampled patients with diabetes and/or hypertension to demonstrate that our taxonomy could be applied to different health conditions, and to highlight any differences in taxa use based on health condition. We included threads initiated and completed between January 1 and December 31, 2017. Our study included 2111 patients, of whom 49 percent initiated 7346 threads that included 10163 patient-generated messages and 8146 messages generated by 674 unique clinic staff (hereafter referred to as clinician-generated messages). Patient and Clinic Staff Characteristics Associated with Message Content In the first paper, we described the coding process and interrater and intrarater reliability derived from that process, and then presented our findings on the characteristics of the senders and receivers associated with selected taxa. We estimated both unadjusted and adjusted differences in characteristics associated with the use of each taxon. We assessed taxon use as a dichotomous variable that was positive if the patient or clinician sent or received at least one message coded with the selected taxon. For patient-generated taxa, we explored associations with the characteristics of the sender (which types of patients sent these taxa) and receiver (which types of clinic staff received these types of content). Similarly, we explored the associations between clinician-generated taxa and the characteristics of the sender (what types of clinic staff sent these taxa) and receiver (what types of patients were the recipients of this content). We created separate regression models for patient characteristics (demographic, geographic, health condition and status, and thread volume) and staff characteristics (staff type, specialty, and message volume). Our patient-level analyses included only the 1031 patients who initiated message threads using the patient portal. Our analyses found differences in taxa use by patients’ age, sex, race, health condition and status, and distance from clinic. Younger patients and females were less likely to share certain types of information with clinic staff (clinic updates among younger patients OR=0.77; 95% CI: 0.65-0.91; self-reporting biometrics by women OR=0.78; 95% CI: 0.62-0.98). Use of certain types of task-oriented requests varied by age (younger patients’ prescription refills OR=0.77; 95% CI: 0.65-0.90 and scheduling requests OR=1.41; 95% CI: 1.19-1.68) and race (black vs white requests for preventive care appointments OR=2.68; 95% CI: 1.30-5.51, requests for a new or changed prescription OR=0.72; 95% CI: 0.53-0.98, and laboratory or other diagnostic procedures OR=0.66; 95% CI: 0.46-0.95). Younger and uninsured patients were less likely to receive medical guidance from clinic staff (OR=0.84; 95% CI: 0.71-0.99 and OR=0.21; 95% CI: 0.06-0.72, respectively), but patients with public payers were two times more likely to receive medical guidance compared to patients with private payers (95% CI: 1.27-3.24). Females were less likely to receive confirmation that requests were fulfilled (OR=0.81; 95% CI: 0.68-0.97). These findings highlight differences in how patients used secure messaging to communicate with their clinic staff, which could result in differential access to care. Further, the differences in taxa use by clinic staff by patients’ characteristics might further exacerbate existing disparities in care and highlight opportunities for training and education to reduce these discrepancies. Healthcare Services Utilization Associated with Message Content The Street, Makoul, et al. (2009) framework highlights access to care as an intermediate outcome in the pathway between health outcomes and communication functions such as information exchange, enabling self-care, and making decisions. Patients reported that effective communication delivered through secure messaging prevented unnecessary appointments (Alpert, Markham, Bjarnadottir, & Bylund, 2019); however, prior studies that explored links between secure messaging and healthcare utilization only considered message volume, not what was said in those messages. Our second paper is the first to explore whether content is associated with healthcare utilization. We measured utilization in four ways: number of outpatient visits, number of emergency department visits, number of inpatient visits, and medication adherence. We created separate medication adherence dichotomous variables for diabetes and hypertension, based on having an average condition-specific medication possession ratio greater than 0.8 (Clifford, Perez-Nieves, Skalicky, Reaney, & Coyne, 2014; Khunti, Seidu, Kunutsor, & Davies, 2017; Krass, Schieback, & Dhippayom, 2015; Schulz et al., 2016). We measured our independent variables as the taxon prevalence among patient- or clinician-generated taxa, as appropriate. Our covariates included the patient characteristics described in the first paper. To estimate incidence rate ratios for the three visit dependent variables, we conducted Poisson regressions with robust variance estimation (Hilbe, 2014). We estimated the odds of medication adherence associated with each taxon using logistic regression. In unadjusted analyses, we found that patients who initiated message threads had higher numbers of outpatient visits (p\u3c0.0001) and better hypertension medication adherence (p\u3c0.01), compared to patients who did not initiate threads. Among patients who initiated message threads, we identified a positive association between emergency department visits and prevalence of request denials from clinic staff (IRR=1.18; 95% CI: 1.03, 1.35) and patients’ requests for follow-up appointments (IRR=1.15; 95% CI: 1.07-1.23), as well as between clinic non-response and the number of outpatient visits (IRR=1.02; 95% CI: 1.00, 1.03). We identified an inverse association between hypertension medication adherence and patients’ appointment reschedule requests (OR=0.87; 95% CI: 0.79-0.96). These findings highlight opportunities for future research about the use of secure messaging to influence care delivery and access to care. Patient Health Outcomes Associated with Message Content Patients whose uncertainty in their illness is addressed experience less stress, leading to better health outcomes (Mishel, 1988). Through appropriate communication functions with clinicians, patients develop better understanding of their condition and how to manage it and may have improved access to care and self-care skills, which leads to better outcomes (Street, Makoul, et al., 2009). Our third paper describes the first study to assess the types of message content associated with improved health outcomes. We examined changes in patients’ glycemic index (A1C) for patients with diabetes and changes in diastolic (DBP) and systolic blood pressure (SBP) among patients with hypertension, comparing patients who sent or received messages with selected taxa to (1) those who sent other types of messages and (2) those who did not initiate threads in 2017. We measured outcome changes as the difference between baseline (the last measured value in 2016) and endpoint (the first measured value reported in 2018) measures. Similar to the analyses conducted for Paper 2, our independent variables were the prevalence of each taxon by patient, where the denominator was the number of patient- or clinician-generated taxa, as appropriate for the selected taxon. Analyses included only patients with the selected condition: 811 patients with diabetes only, 787 patients with hypertension only, and 513 patients with both conditions. We used linear regression to identify associations between the outcomes and each taxon. In unadjusted analyses, we found that patients who initiated threads had lower endpoint A1Cs (p=0.01) compared to patients who did not initiate threads. We observed improvements in A1C among patients who sent information seeking messages (b=-0.07; 95% CI: -0.13, -0.00). We also observed improved SBP associated with clinic non-response to patients’ threads (b=-0.30; 95% CI: -0.56, -0.04), staff acknowledgement and fulfillment of patients’ requests (b=-0.30; 95% CI: -0.58, -0.02), and patients’ complaints (b=-4.03; 95% CI: -7.94, -0.12). Poorer outcomes were associated with information sharing messages among patients with diabetes (b=0.08; 95% CI: 0.01, 0.15), and deferred information sharing by clinic staff among patients with hypertension (SBP b=1.29; 95% CI: 0.4-2.19). In addition, among patients with either condition, we observed positive associations between outcome and patient- and clinician-generated appreciation and praise messages with effect sizes ranging from 0.4 (A1C) to 5.69 (SBP). These findings demonstrate associations between outcomes and message content and further emphasize the need for training and education of clinic staff on appropriate use of secure messaging to prevent exacerbation of health disparities due to differential communication delivered through this modality. Conclusion We identified patient characteristics associated with patients’ use of taxa; not surprisingly, patients’ use of taxa varied by age, sex, and race. Taxa use varied by clinic staff characteristics consistent with the triage systems employed by most healthcare organizations (Heyworth et al., 2013; Ozkaynak et al., 2014; Wooldridge, Carayon, Hoonakker, Musa, & Bain, 2016). We also identified differences in staff’s taxa use based on the characteristics of the patient to whom they were sending the message. We further identified associations between taxa and healthcare utilization and health outcomes. If certain types of patients use taxa less frequently, and these taxa are associated with better outcomes or more appropriate utilization, then that presents opportunities to target those populations for education to shift their use of secure messaging. Further, if clinician-generated message content is associated with improved outcomes and clinic staff are not equitably sharing that content with all patients, there is an opportunity for education and training. Our research is a set of first-of-its-kind analyses that highlight differences in taxa use by both patients and clinicians and demonstrates the associations between those taxa and patient outcomes. Healthcare administrators and clinic staff should be aware of these associations and consider mitigation strategies to improve equitable secure messaging use by their staff and across their patient populations. The studies shared several limitations discussed in more detail in the papers themselves. These limitations included a need for more specificity in the taxa definitions and more rigorous coding processes, the lack of temporal indicators in the analysis, and limited patient and clinical characteristics. The analyses that incorporated A1C measurements suffered from significant missing data. Sample size for some taxa was limited so that the algorithms did not converge. The analyses were based on single taxa, which represented only one component of the overall thread discussion. Finally, our message sample included only those messages saved to patients’ charts, which likely led to an underrepresentation of taxa and clinic non-response. We highlighted a number of opportunities for future research across the three studies. Consideration should be given to refining taxa definitions and applying more rigorous coding practices, incorporating temporal elements into the analyses to provide context and support assessments of causality, adding relevant covariates such as message reading level or patients’ health literacy levels, and exploring other proximal and intermediate outcomes identified in the Street, Makoul, et al. (2009) framework. We also strongly recommend examining the impact of taxa pairings: analyses that consider the call-and-response nature of the full conversation occurring within the thread

PATIENT PORTAL USE AND ITS ASSOCIATION WITH CLINICAL OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES

Background: The rapid growth of type 2 diabetes mellitus (T2DM) in the United States presents significant challenges. Patient portals are promising tools that address the increasing number of individuals with T2DM and engage these people in the process of managing their chronic condition. Objectives: The purposes of this study were: 1) to describe the portal usage pattern by individuals with T2DM over the two-year study period; 2) to identify whether sociodemographic, socioeconomic, and clinical characteristics differ between portal users and non-users; and 3) to longitudinally examine the effect of portal use on glycemic control in patients with T2DM. Methods: This two-year retrospective, observational cohort study utilized data from the ambulatory electronic health records (EHR) of the University of Pittsburgh Medical Center (UPMC) Physician Services and its ancillary patient portal. The study included adults seen in an outpatient setting of UPMC between January 2015 and December 2016. We applied descriptive statistics to describe sample characteristics and portal usage patterns. Logistic regression was used to examine factors associated with portal use. A propensity score matching (PSM) technique was conducted to equate the portal user and non-user groups, and mixed modeling was performed to examine the effect of portal use on hemoglobin A1c (HbA1c) over time. Results: Nearly one-third of the individuals (n=12,615, 32.9%, 95% CI: [32.3%,33.3%]) with T2DM used the portals. An increased portal usage was observed before and after a physician visit, and on weekdays compared to weekends (p<0.001). In general, we found associations of age, race, income, and the number of chronic conditions with portal usage, and several other predictors modified these effects (ps<0.05). After PSM, both groups showed a non-linear decline of HbA1c over time (p<.001), and the portal users (n=4,924) demonstrated a greater decrease and better maintenance than the non-users (n=4,924, p<.001). Conclusions: Our findings highlight the promising effect of a patient portal on clinical glycemic control in persons with T2DM. Disparities in patient portals need to be addressed to bridge the existing gaps in diabetes outcomes. Future study should explore mechanisms through which the portal contributes to better clinical outcomes to guide evidence-based portal design and implementation

Use of Secure Messaging By United States Veterans and Significant Others

ABSTRACT USE OF SECURE MESSAGING BY UNITED STATES VETERANS AND SIGNIFICANT OTHERS By Claudia S. Derman The University of Wisconsin-Milwaukee, 2014 Under the Supervision of Professor Karen H. Morin, PhD, RN, ANEF, FAAN The purpose of this study was to describe the topics discussed using secure messaging (SM), the pattern of use of SM, and whether the themes discussed and/or the pattern of use varied based on gender and age of the SM user. Secure messaging is an example of a technology that focuses on patient-centered communication. Secure messaging allows patients to communicate with their clinicians using the Internet and at their convenience, while maintaining the privacy of the information exchanged. Secure messages, if approved by the patient, may also be written by family members or significant others for the patient. By its nature, the use of SM is indicative of an individual\u27s involvement in their healthcare, utilizing self-management skills. Few studies were found that reported on the content of messages written by patients or their families. No studies were found that reviewed the topics patients write about in these secure messages nor were studies found that tracked the number of messages written by patients and relating to the days and time that were most utilized. A review of 1200 secure messages written by veterans and their caregivers was undertaken to determine what information was contained within the secure messages. The 1200 messages contained 1720 themes that were grouped using content analysis to yield a total of ten topics. The day of week and the time of day of messages were additionally reviewed by gender and age of the individual. Messages written by friends of family members were reviewed and compared to those written by patients. The topic most addressed as that of medications, with more than one-third of the 1720 themes within messages relating to medications. Veterans aged 55 to 64 years were the greatest users of the SM system followed closely by those between the ages of 65 to 74. Men wrote most frequently about medications while women wrote more themes related to the topics of complaints and concerns and consultations with specialists. Pattern of use of relative to time of day and day of the week was also reviewed in subset of the sample (n= 600). The most common time frame during which messages were sent was between 9:00 a.m. and 6 p.m., accounting for more than 70% of all messages. Tuesdays and Thursdays were the most often utilized days of week for SM. The implications of this study include revisiting how MyHealtheVet is configured to enhance the veteran\u27s ability to communicate effectively and appropriately with healthcare providers. It is possible that participants employed SM rather than other identified means to contact providers as they were assured of a response within a defined period of time. Findings have implications for users, clinicians, hospital administrators, and technical staff. The purposes of SM can be revisited with users, clinicians may wish to consider alternative strategies, and administrators may wish to revisit the current structure in terms of identifying a method to sort the information contained in SM

Effect of healthcare personnel in e-health interventions on glycated haemoglobin in adults with type 2 diabetes - a systematic review

This systematic review shows that providing e-health with tailored HCP feedback to patients with type 2 diabetes, does not have added health benefits when the control group also receives e-health. While all of the included studies had some reduction in HbA1c levels, none of the study groups reach treatment target of HbA1c, less than 7%. Furthermore, there was no clinically relevant impact on blood pressure, low density lipoprotein or weight. The review studies were highly heterogeneous, with different characteristics of participants, interventions and control conditions. There is a need for additional high quality RCTs and subsequently systematic reviews in order to draw firm conclusions about the effect of including HCP in e-health interventions. For policy makers to assess the overall effectiveness of HCP involvement in e-health interventions, future reviews must also address other types of diabetes related outcomes. Furthermore, future primary studies must address the long-term effects of HCP involvement in e-health when it comes to cost-effectiveness and patient utilization

Telemedicine and mHealth interventions for children and young people with type one diabetes (T1DM)

Open access journa

A Systems-Based Patient Aid Design Artifact for Active Medication Management in Type 2 Diabetes

In this dissertation, I explore the use of the Abstraction-Decomposition Space (ADS) alongside Hierarchical Task Analysis (HTA) to guide the design of a minimalist patient aid for active medication management in type 2 diabetes. The goal is to address a practical problem, but in addition, this study seeks to address a theoretical problem that is prevalent in design research in Information Systems (IS) today. The practical problem concerns the need for IT-based care delivery models to support patients in the interim period between in-person visits. In this vein, I present a bare-minimum design that focuses on the most essential functionality required to achieve remote insulin titration using the ADS and HTA. The theoretical problem, on the other hand, pertains to the limitations resulting from taking a tool-focused view in design research which inhibits our ability to produce generalized knowledge about IT systems in their contexts. The study proposes an alternative view based on work systems. The overarching thesis is that a work systems view provides for knowledge at a more abstract and generalizable level, yielding contributions beyond mere software packages. Moreover, the study highlights the artifact-building methodology used to delineate the rationale behind the design and to balance evaluation-dominant design research. In this vein, I conducted document analysis and semi-structured interviews with patients and care providers to develop the ADS, then used it alongside HTA to develop and test the usability of twelve user scenarios implemented on a large mobile form factor

Novel Health Mobile Technology as an Emerging Strategy in Diabetes Management

Advances in mobile phone technology and its applications coupled with equally robust growth of telecommunication technology can serve to give patients a better access to the healthcare. More and more healthcare providers and patients started using these applications. Mobile applications are useful in handling various aspects of healthcare namely, health promotion and disease prevention, diagnosis, treatment, monitoring and supporting health services. Clinical studies evaluating mobile applications often come up with mixed results. In this chapter, application of mobile health technology or mHealth in diabetes management is presented as a case study. We have reviewed 25 articles from pubmed database that fulfilled our selection criteria which included original clinical studies that evaluated mobile health technology in the management of diabetes mellitus. Most studies (88%) reported positive outcomes after use of the mobile health applications in various aspects of diabetes treatment such as disease management, behavioural monitoring and patient education. Educational SMS were effective but inferior to Smartphone Apps or teleconsultations. User-friendliness of the systems influenced patient compliance and outcomes. Smartphone/web applications offer significant benefits for patient care, education and behavioural modifications. As providing continuous patient support would require adequate infrastructure and personnel, cost effectiveness of such interventions need to be studied

Patient Use of the Electronic Communication Portal in Management of Type 2

University of Minnesota Ph.D. dissertation. June 2015. Major: Nursing. Advisors: Karen Monsen, Kathleen Krichbaum. 1 computer file (PDF); ix, 131 pages.The high incidence and prevalence of Type 2 Diabetes require urgent attention to the management of this chronic disease. Previous studies present the advantages of e-communication via the patient portal to access Electronic Medical Records (EMR) by patients. The purpose of this study was to explore e-communication between patients with Type 2 Diabetes and their providers within the patient portal in one of the Midwest healthcare systems. The study employed a qualitative design, based on the use of content analysis methods. Conversation Theory served as the theoretical framework. A purposive, random sample of 90 charts of patients with Type 2 Diabetes in a Midwestern health system was subjected to a retrospective review of the e-communication within the patient portal. The sample consisted of patients between the ages of 50 and 70, the majority of whom were White, Non-Hispanic, English-speaking, and married. Patients were described as receiving good care, with the mean duration of Diabetes at 8.41 years. Patients were also relatively experienced in using the patient portal. The three main themes that emerged in the e-communication via patient portal were the Inform Theme, the Question Theme, and the Instruct/Request Theme. The Inform theme was the most frequently identified; the Instruct/Request Theme was mainly used in initiation of e-communication. The Question Theme was the least frequently observed of the three themes in e-message encounters. The fit with Conversation Theory revealed that most of the staff-initiated e-message encounters fit within the monolog type, while most of the patient-initiated e-message encounters fit within the dialogue type. Dialectic and construction types of conversation were very rare. Limitations of the study include the bias of the researcher, and lack of certain data in EMR. There is a need to develop standardized templates for Type 2 Diabetes e-communication via patient portal to capture complete data from the patients, and to promote diabetes education via patient portal using a construction type of conversation. Healthcare system guidelines should include information about the initiation and the use of e-communication via patient portal, and specifically target engaging patients who are not meeting desired diabetes care outcomes