After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews

Associations between blood pressure control and clinical events suggestive of nutrition care documented in electronic health records of patients with hypertension

BACKGROUND

Clinical events suggestive of nutrition care found in electronic health records (EHRs) are rarely explored for their associations with hypertension outcomes.

METHODS

Longitudinal analysis using structured EHR data from primary care visits at a health system in the US from December 2017-December 2020 of adult patients with hypertension (n = 4,237) tested for associations between last visit blood pressure (BP) control (≤ 140 Systolic BP and ≤ 90 Diastolic BP) and ≥ 1 nutrition care clinical event operationalized as (overweight or obesity (BMI > 25 or 30, respectively) diagnoses, preventive care visits, or provision of patient education materials (PEM)). Descriptive statistics and longitudinal targeted maximum likelihood estimation (LTMLE) models were conducted to explore average treatment effects (ATE) of timing and dose response from these clinical events on blood pressure control overall and by race.

RESULTS

The median age was 62 years, 29% were male, 52% were Black, 25% were from rural areas and 50% had controlled BP at baseline. Annual documentation of overweight/obesity diagnoses ranged 3.0-7.8%, preventive care visits ranged 6.2-15.7%, and PEM with dietary and hypertension content were distributed to 8.5-28.8% patients. LTMLE models stratified by race showed differences in timing, dose, and type of nutrition care. Black patients who had nutrition care in Year 3 only compared to none had lower odds for BP control (ATE -0.23, 95% CI: -0.38,-0.08, p = 0.003), preventive visits in the last 2 years high higher odds for BP control (ATE 0.31, 95% CI: 0.07,0.54, p = 0.01), and early or late PEMs had lower odds for BP control (ATE -0.08, 95% CI: -0.15,-0.01, p = 0.03 and ATE -0.23, 95% CI: -0.41,-0.05, p = 0.01, respectively).

CONCLUSIONS

In this study, clinical events suggestive of nutrition care are significantly associated with BP control, but are infrequent and effects differ by type, timing, and patient race. Preventive visits appear to have the most effect; additional research should include examining clinical notes for evidence of nutrition care among different populations, which may uncover areas for improving nutrition care for patients with chronic disease.

Associations between Blood Pressure Control and Documented Nutrition Care Using Structured Data from Electronic Health Records of Patients with Hypertension

Background

Documentation in Electronic Health Records (EHRs) of nutrition care events (overweight or obesity (BMI > 25 or 30, respectively) diagnoses, preventive care visits, or provision of patient education materials (PEM)) for chronic diseases is unclear.

Methods

Cross-sectional analysis using structured EHR data from primary care visits at a health system in the US from January 2018 - December 2020 of adult patients with hypertension (n = 6,419) tested for associations between last visit blood pressure (BP) control (≤ 140 Systolic BP and ≤ 90 Diastolic BP) and aggregate nutrition care events. Descriptive statistics and multiple logistic regression models were constructed to examine the predictive power of nutrition care events for blood pressure control.

Results

The median age was 62 years, 32% were male, 48% were Black, 26% were from rural areas and 35.9% had controlled BP at last visit. For the 62% of patients with documented nutrition care, 14.6% had an overweight/obesity diagnosis, 26.2% had a preventive care visit, and 42% received PEM with dietary and hypertension content. The models showed patients who had more preventive care visits (aOR 1.12; CL 1.06, 1.18) had higher odds for BP control. Whereas Black patients compared with white patients (aOR 0.84; CL 0.74, 0.95), those with more hypertension medications (aOR 0.97; CL 0.96, 0.99) and more primary care visits over the study period (aOR 0.98; CL 0.97, 0.99) had lower odds for BP control.

Conclusions

In this study, documented nutrition care in preventive care visits is significantly associated with BP control, but documentation is infrequent. Additional research should include examining clinical notes for evidence of nutrition care, which may uncover areas that show promise for improving nutrition care for patients with chronic disease.

Use and Usefulness of After-Visit Summaries by Language and Health Literacy among Latinx and Chinese Primary Care Patients

The after-visit summary (AVS), a document generated from the electronic health record that summarizes patients' encounters with the healthcare system, is a widely used communication tool. Its use by and usefulness for populations with limited English proficiency (LEP) and limited health literacy (LHL) is poorly understood. In this cross-sectional study, we assessed use and usefulness of the AVS among English-, Spanish-, Cantonese-, or Mandarin-speaking Latinx and Chinese primary-care patients. Outcome measures were self-reported AVS use (did not use/looked-at only/shared only/looked-at and shared) and usefulness (useful/not useful). Among 993 participants, 57% were ≥65 years old, 61% had LEP, 21% had LHL, 30.2% were Latinx, 69.8% were Chinese. The majority used the AVS (86%) and found it useful (65%). In adjusted models, participants with LEP were more likely to "look at" (OR 1.68, 95% CI 1.07-2.62) and "look at and share" (OR 1.65, 1.02-2.66) the AVS, but less likely to find it useful (OR 0.68, 0.47-0.98) compared to English speakers. Those with LHL were less likely to "look at" (OR 0.60, 0.39-0.93) and less likely to find the AVS useful (OR 0.67, 0.46-0.99) compared to those with adequate health literacy. Our results emphasize the need for easy-to-understand and fully language-concordant AVS.

Patient-Reported Use of the After Visit Summary in a Primary Care Internal Medicine Practice

Participants completed a cross-sectional survey about their use of the after visit summary (AVS) at a previous primary care visit. Of 355 participants, 294 (82.8%) recalled receiving it, 67.4% consulted it, 45.9% consulted it more than once, and 31.6% shared the AVS. In multivariable analysis, higher education and older age were associated with AVS consultation. Among the subset of 133 patients recalling personalized free-text instructions, 96% found them easy to understand and 94.4% found them useful. Our findings suggest that the AVS is a useful communication tool and improvement efforts should emphasize clarity for those most vulnerable to communication errors.