Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis

BACKGROUND: Rural patients with diabetes have difficulty accessing care and are at higher risk for poor diabetes management. Sustained use of patient portal features such as secure messaging (SM) can provide accessible support for diabetes self-management. OBJECTIVE: This study explored whether rural patients\u27 self-management and glycemic control was associated with the use of SM. METHODS: This secondary, cross-sectional, mixed methods analysis of 448 veterans with diabetes used stratified random sampling to recruit a diverse sample from the United States (rural vs urban and good vs poor glycemic control). Administrative, clinical, survey, and interview data were used to determine patients\u27 rurality, use of SM, diabetes self-management behaviors, and glycemic control. Moderated mediation analyses assessed these relationships. RESULTS: The sample was 51% (n=229) rural and 49% (n=219) urban. Mean participant age was 66.4 years (SD 7.7 years). More frequent SM use was associated with better diabetes self-management (P=.007), which was associated with better glycemic control (P \u3c .001). Among rural patients, SM use was indirectly associated with better glycemic control through improved diabetes self-management (95% CI 0.004-0.927). These effects were not observed among urban veterans with diabetes (95% CI -1.039 to 0.056). Rural patients were significantly more likely than urban patients to have diabetes-related content in their secure messages (P=.01). CONCLUSIONS: More frequent SM use is associated with engaging in diabetes self-management, which, in turn, is associated with better diabetes control. Among rural patients with diabetes, SM use is indirectly associated with better diabetes control. Frequent patient-team communication through SM about diabetes-related content may help rural patients with diabetes self-management, resulting in better glycemic control

Secure Messaging, Diabetes Self-management, and the Importance of Patient Autonomy: a Mixed Methods Study

BACKGROUND: Diabetes is a complex, chronic disease that requires patients\u27 effective self-management between clinical visits; this in turn relies on patient self-efficacy. The support of patient autonomy from healthcare providers is associated with better self-management and greater diabetes self-efficacy. Effective provider-patient secure messaging (SM) through patient portals may improve disease self-management and self-efficacy. SM that supports patients\u27 sense of autonomy may mediate this effect by providing patients ready access to their health information and better communication with their clinical teams. OBJECTIVE: We examined the association between healthcare team-initiated SM and diabetes self-management and self-efficacy, and whether this association was mediated by patients\u27 perceptions of autonomy support from their healthcare teams. DESIGN: We surveyed and analyzed content of messages sent to a sample of patients living with diabetes who use the SM feature on the VA\u27s My HealtheVet patient portal. PARTICIPANTS: Four hundred forty-six veterans with type 2 diabetes who were sustained users of SM. MAIN MEASURES: Proactive (healthcare team-initiated) SM (0 or \u3e /= 1 messages); perceived autonomy support; diabetes self-management; diabetes self-efficacy. KEY RESULTS: Patients who received at least one proactive SM from their clinical team were significantly more likely to engage in better diabetes self-management and report a higher sense of diabetes self-efficacy. This relationship was mediated by the patient\u27s perception of autonomy support. The majority of proactive SM discussed scheduling, referrals, or other administrative content. Patients\u27 responses to team-initiated communication promoted patient engagement in diabetes self-management behaviors. CONCLUSIONS: Perceived autonomy support is important for diabetes self-management and self-efficacy. Proactive communication from clinical teams to patients can help to foster a patient\u27s sense of autonomy and encourage better diabetes self-management and self-efficacy

Impact of Patient-Clinical Team Secure Messaging on Communication Patterns and Patient Experience: Randomized Encouragement Design Trial

BACKGROUND: Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care. OBJECTIVE: Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA\u27s online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed. METHODS: We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams. RESULTS: Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; P \u3c .001). Most adopters in the SAP sent their first message without a motivational interview (71/101, 70.3%). The 10-percentage point difference in adoption persisted a full year after the encouragement ended (23.7%, 142/600 in the SAP group vs 13.5%, 80/595 in the control group, P \u3c .001). We obtained follow-up survey data from 49.54% (592/1195) of the participants. SAP participants reported higher perceived provider autonomy support (5.7 vs 5.4, P=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%). CONCLUSIONS: The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties. TRIAL REGISTRATION: ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468

Creating Emergency Department Point-of-Care Testing Protocols: An Expert Panel and Delphi Process

In recent years, point-of-care (POC) testing has gained popularity in emergency departments (EDs) to facilitate rapid laboratory test results 1 2 3 4 . Despite increasing popularity, few studies have addressed POC use early in ED care, specifically around ED triage. Availability of laboratory testing may help risk-stratify patients by providing additional information early in ED care. In a prospective study, triage POC testing changed patient management in 14% of cases, Emergency Severity Index (ESI) triage level in 15%, and 56% found POC testing to be helpful in the triage process [5] . In addition, POC may hasten ED care through early ordering of symptom appropriate diagnostic tests—a process called rapid posttriage assessment [6 7] . In this project, we convened an expert panel to identify priorities for ED POC testing and created 2 protocols intended for early care of ED patients. One protocol focuses on early prioritization for time-sensitive conditions, and a second is a rapid posttriage assessment POC protocol. We convened a technical expert panel and used a Delphi process to create 2 protocols for ED POC testing. The goal was to seek input to develop these protocols using a consensus-seeking methodology using expert guidance followed by multiple rounds of structured questionnaires. In our study, we used 2 rounds of structured questionnaires to solicit opinions; resolve areas disagreement; and, where possible, achieve consensus. The protocols were designed to aid nurses in deciding which POC to order for ED patients with specific symptoms

Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain

© 2020 by the Society for Academic Emergency Medicine Objective: We compare utilization of diagnostic resources and admissions in emergency department (ED) patients with chest pain and abdominal pain when managed by advanced practice providers (APPs) and physicians. Methods: We used 2016 to 2019 data from a national emergency medicine group. We compared visits managed by physicians and APPs based on demographics and observed resource utilization (labs, radiography, computed tomography) use and hospital admission/transfer, stratified by patient age. To reduce selection bias, we created inverse propensity score weights (IPWs). To estimate the average treatment effect for APP visits for each outcome, we included IPWs in a multivariable linear probability model with a dummy variable indicating treatment by an APP and used a facility fixed effect. We then estimated the average treatment effect comparing physician to APP visit for all visits and for discharged visits separately, stratified by the study outcomes. Sensitivity analyses were performed using different cohort definitions and adjusting for past medical history. Results: In chest pain, we included 77,568 visits seen by 1,011 APPs and 586,031 visits seen by 1,588 physicians. In abdominal pain, we included 184,812 ED visits seen by 1,080 APPs and 761,230 visits seen by 1,689 physicians. For both chest pain and abdominal pain visits, physicians saw more older adult patients (55+ years) and admitted a higher percentage of visits than APPs. For chest pain, physicians saw more circulatory system diseases (70.7% vs. 58.6%); APPs saw more respiratory system diseases (17.1% vs. 9.8%). In abdominal pain, emergency physicians saw more digestive system diseases (28.5% vs. 23.3%); APPs saw more genitourinary system diseases. After matching with IPW, predicted probabilities of laboratory, radiology, and admissions either did not vary or were slightly lower for APPs compared to physicians for all outcomes. Sensitivity analyses showed similar results, including controlling for past medical history. Conclusion: Diagnostic testing and hospitalization rates for chest pain and abdominal pain between APPs and physicians is largely similar after matching for severity and complexity. This suggests that APPs do not have observably higher use of ED and hospital resources in these conditions in this national group

The Effect of Point-of-Care Testing at Triage: An Observational Study in a Teaching Hospital in Saudi Arabia

Introduction: Prolonged waiting times during episodes of emergency department (ED) crowding are associated with poor outcomes. Point-of-care testing (POCT) at ED triage prior to physician evaluation may help identify critically ill patients. We studied the impact of ED POCT in a single ED with a high degree of crowding for patients with high-risk complaints who were triaged as non-critically ill. Methods: We conducted the study from April–July 2017 at King Abdulaziz University (KAU) Hospital in Jeddah, Saudi Arabia. Patients with one of seven complaints received triage POCT. The primary outcome was whether POCT results at triage resulted in immediate transfer of the patient from the waiting room into the ED. Secondary outcomes were whether the triage nurse felt that the POCT results were useful, and whether triage POCT changed triage acuity. We used simple descriptive statistics to summarize the data. Results: A total of 94 patients were enrolled and received i-STAT® POCT. The most common symptoms and triage protocols were for chest pain (42%), abdominal pain (31%), and shortness of breath (22%). In 11 cases (12%), care was changed as a result of triage POCT. In 12 cases (13%), triage level was changed. The triage nurse found POCT helpful in 93% of cases. Conclusion: In this ED, triage POCT was a helpful adjunct at ED triage and resulted in immediate care (transfer to an ED room) in one in eight cases. Therefore, POCT at triage may be a useful adjunct to improve patient safety, particularly in crowded EDs

Estimating the uncertain effect of the COVID pandemic on drug overdoses

OBJECTIVE: U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Many academic studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may have reflected a continuation of pre-pandemic trends in synthetic-opioid deaths, which began to rise in mid-2019. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be related primarily to the COVID-19 pandemic, increased synthetic-opioid use, or some of both. METHODS: We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015-2021); CDC data on monthly ED visits (2019-September 2020) for EDs in 42 states; and ED visit data for 181 EDs in 24 states staffed by a national ED physician staffing group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, in both cases compared to predicted levels based on pre-pandemic trends. RESULTS: Mortality. National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The rise in mortality began in mid-to-late half of 2019, and the 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual mortality, relative to mortality predicted based on pre-pandemic trends, show no consistent pattern. The state-level results support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality. ED visits. ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods. CONCLUSION: The reasons for rising overdose mortality in 2020 and 2021 cannot be definitely determined. We lack a control group and thus cannot assess causation. However, the observed increases can be largely explained by a continuation of pre-pandemic trends toward rising synthetic-opioid deaths, principally fentanyl, that began in mid-to-late 2019. We do not find evidence supporting the pandemic as a major driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes