Outpatient portal use in prenatal care: differential use by race, risk, and area social determinants of health

A Pilot Analysis of Patient Portal Use and Breast Cancer Screening Among Black Patients in a Large Academic Health System

Introduction

Patient portals may facilitate breast cancer screening and could be an important factor to address inequities; however, this association is not well characterized. The authors sought to examine this association in a large academic health system to inform interventions to address breast cancer screening inequities.

Methods

The authors conducted a cross-sectional study among Black patients in a large academic health system using logistic regression to examine the association between breast cancer screening and portal use, adjusting for multilevel covariates and interactions. The authors estimated average marginal effects to examine the additive probability of breast cancer screening completion given portal use in the prior 12 months.

Results

In the unadjusted model, portal use was associated with an estimated mean 24.8 percentage points (95% CI=20.7, 29.0) increased likelihood of completing breast cancer screening. In the adjusted model, portal use was associated with an estimated mean 16.2 percentage points (95% CI=11.2, 21.3) increased likelihood for completing breast cancer screening.

Conclusions

Improving portal access and use among racialized groups who face both portal and breast cancer screening inequities could be one strategy to address inequities. These pilot data will inform subsequent community-engaged research to better understand this association and develop and test a portal intervention to facilitate breast cancer screening access among Black patients eligible for screening.

Patient and provider perspectives on the use of patient portals during pregnancy and the postpartum period

INTRODUCTION

Interest in the use of patient portals to support prenatal and postpartum care is growing. This study was conducted to understand patient and provider perspectives about the impact of portal use during pregnancy and the postpartum period.

METHODS

Interviews were conducted with 30 pregnant or postpartum patients and 15 obstetric care providers at an academic medical center that offers its patients access to an outpatient portal. Interview transcripts were analyzed deductively and inductively to categorize findings and identify emergent themes.

RESULTS

Patients and providers described how use of a patient portal during pregnancy and postpartum impacted communication (by supporting convenient communication and access to information), care processes (by aiding appointment attendance and helping with medication management), and care experience (by reducing anxiety and promoting patient involvement). Interviewees provided suggestions to improve patient portal use in obstetric care including using portals to increase access to educational materials and supportive resources, to collect patient-generated data, and to increase patient involvement in postpartum care.

DISCUSSION

Patient portals have particular value for patients' use during pregnancy and the postpartum period due to the frequency of healthcare visits and the heightened attention to one's health during this time. There are opportunities to tailor portal content and functions to patients' needs to improve communication, care processes, and care experiences for this patient population. Further improving the functionality of patient portals for patients' use during pregnancy and the postpartum period has the potential to positively impact patient experiences and health outcomes.

Association Between Patient Portal Engagement and Weight Loss Outcomes in Patients After Bariatric Surgery: Longitudinal Observational Study Using Electronic Health Records

BACKGROUND

Bariatric surgery is an effective intervention for obesity, but comprehensive postoperative self-management is essential for optimal outcomes. While patient portals are generally seen as beneficial in engaging patients in health management, the link between their use and post-bariatric surgery weight loss remains unclear.

OBJECTIVE

This study aimed to investigate the association between patient portal engagement and postoperative BMI reduction among patients after bariatric surgery.

METHODS

This retrospective longitudinal study included patients who underwent Roux-en-Y gastric bypass or sleeve gastrectomy at Vanderbilt University Medical Center between January 2018 and March 2021. Patient portal engagement was measured during 4 stages: early (within 3 months after surgery), early midterm (3-6 months), late midterm (6-9 months), and late (9-12 months). Using generalized estimating equations, we estimated the associations between patients' portal engagements at these stages and the percentage of BMI reduction (%BMIR) at 3, 6, and 12 months after surgery. Covariates included duration since surgery, patient's age at the time of surgery, sex, race and ethnicity, type of bariatric surgery, severity of comorbid conditions, and socioeconomic disadvantage.

RESULTS

The study included 1415 patients, predominantly female (n=1145, 80.9%), with a racial composition of 76.9% (n=1088) White and 19.9% (n=282) Black. Overall, 805 (56.9%) patients underwent Roux-en-Y gastric bypass and 610 (43.1%) underwent sleeve gastrectomy. By 1 year after surgery, the median %BMIR was 31.5% (IQR 25.2%-36.8%), and the median number of active days on the patient portal was 54 (IQR 33-80). Early portal engagement was significantly associated with %BMIR at various postoperative times. Specifically, each additional 10 days of early portal engagement was associated with a 0.37% (95% CI -0.55% to -0.18%; P<.001) lower expected %BMIR at 3 months, a 1.11% (95% CI 0.82%-1.41%; P<.001) higher expected %BMIR at 6 months, and a 0.78% (95% CI 0.25%-1.31%; P=.004) higher expected %BMIR at 12 months. Furthermore, early midterm portal engagement was associated with a 0.36% (95% CI -0.69 to -0.03; P=.03) lower expected %BMIR at 6 months, but it was not significant at 12 months (P=.88). Late midterm and late portal engagement were not significantly associated with %BMIR at 12 months (P=.27 and P=.12, respectively). Furthermore, early engagement in various portal functions, such as messaging and accessing medical records, was significantly associated with a lower %BMIR at 3 months and a higher %BMIR at both 6 and 12 months (all P<.05).

CONCLUSIONS

Higher patient portal engagement within 3 months after surgery-suggestive of stronger adherence to postoperative instructions and improved communication with care teams-is associated with less favorable weight loss immediately after surgery but enhanced postoperative weight loss outcomes at 6 and 12 months. However, the limitations of retrospective data-driven studies highlight the need for future intervention-based studies to validate these associations and establish causality.

Social Determinants of Health and Diabetes in Pregnancy

Social determinants of health (SDOH) are the conditions in which people are born, grow, work, live, and age. SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes for different populations and can be measured at both an individual and neighborhood or community level (iSDOH, nSDOH). In pregnancy, increasing evidence shows that adverse iSDOH and/or nSDOH are associated with a greater likelihood that diabetes develops, and that when it develops, there is worse glycemic control and a greater frequency of adverse pregnancy outcomes. Future research should not only continue to examine the relationships between SDOH and adverse pregnancy outcomes with diabetes but should determine whether multi-level interventions that seek to mitigate adverse SDOH result in equitable maternal care and improved patient health outcomes for pregnant individuals living with diabetes. KEY POINTS: · SDOH are conditions in which people are born, grow, work, live, and age.. · SDOH are systemic factors that may explain, perpetuate, and exacerbate disparities in health outcomes.. · SDOH can be measured at the individual and neighborhood level.. · Adverse SDOH are associated with worse outcomes for pregnant individuals living with diabetes.. · Interventions that mitigate adverse SDOH to improve maternal health equity and outcomes are needed..

Sudden Shift to Telehealth in COVID-19: A Retrospective Cohort Study of Disparities in Use of Telehealth for Prenatal Care in a Large Midwifery Service

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service.

METHODS

We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors.

RESULTS

When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression.

DISCUSSION

No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.

Exploring measurement tools used to assess knowledge, attitudes, and perceptions of pregnant women toward prenatal screening: A systematic review

There is a lack of standardized measurement tools globally to assess knowledge, attitudes, and perceptions of expecting women toward prenatal screening. The purpose of this systematic review was to identify reasons women pursue or decline prenatal screening and compare the strengths and limitations of available measurement tools used to assess pregnant women's perceptions, knowledge, and attitudes toward prenatal screening. This review followed the five-step York methodology by Arksey and O'Malley and incorporated recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist for the extraction, analysis, and presentation of results. The five steps consisted of: (1) identification of the research questions; (2) searching for relevant studies; (3) selection of studies relevant to the research questions; (4) data charting; and (5) collation, summarization, and reporting of results. Four online databases (PubMed, Embase, Web of Science, and Cochrane Library) were selected after the librarian's development of a detailed search strategy. The Rayyan platform was used between June 2023 and August 2023 to epitomize the articles produced from our search. A total of 68 eligible studies were included in the analysis. The top five major reasons for declining prenatal screening uptake included (1) being unsure of the risk of prenatal screening and harm to the baby or miscarriage (n = 15), (2) not considering action such as termination of pregnancy for prenatal screening to be considered as necessary (n = 14), (3) high cost (n = 12), (4) lack of knowledge about testing procedures and being anxious about the test (n = 10), and (5) being worried about probability of false negative or false positive results (n = 6). Only 32 studies utilized scientifically validated instruments. Difficulties in capturing representative, adequately sized samples inclusive of diverse ethnicities and demographics were pervasive. Findings highlight the need for rigorous validation of research measurement methodologies to ensure the accuracy and applicability of resulting data regarding the assessment of prenatal screening perceptions, knowledge, and attitudes across diverse female populations.Registration: N/A.

An Assessment of Patient Portal Messaging Use by Patients With Multiple Chronic Conditions Living in Rural Communities: Retrospective Analysis

BACKGROUND

Patient portals can facilitate the delivery of health care services and support self-management for patients with multiple chronic conditions. Despite their benefits, the evidence of patient portal use among patients with multimorbidity in rural communities is limited.

OBJECTIVE

This study aimed to explore the factors associated with portal messaging use by rural patients.

METHODS

We assessed patient portal use among patients with ≥1 chronic diagnoses who sent or received messages via the Epic MyChart (Epic Systems Corporation) portal between January 1, 2015, and November 9, 2021. Patient portal use was defined as sending or receiving a message through the portal during the study period. We fit a zero-inflated negative binomial model to predict portal use based on the patient's number of chronic conditions, sex, race, age, marital status, and insurance type. County-level characteristics, based on the patient's home address, were also included in the model to assess the influence of community factors on portal use. County-level factors included educational attainment, smartphone ownership, median income, and primary care provider density.

RESULTS

A total of 65,178 patients (n=38,587, 59.2% female and n=21,454, 32.92% Black) were included in the final data set, of which 38,380 (58.88%) sent at least 1 message via the portal during the 7-year study period. As the number of chronic diagnoses increased, so did portal messaging use; however, this relationship was driven primarily by younger patients. Patients with 2 chronic conditions were 1.57 times more likely to send messages via the portal than those with 1 chronic condition (P<.001). In comparison, patients with ≥7 chronic conditions were approximately 11 times more likely to send messages than patients with 1 chronic condition (P<.001). A robustness check confirmed the interaction effect of age and the number of diagnoses on portal messaging. In the model including only patients aged <65 years, there was a significant effect of increased portal messaging corresponding to the number of chronic conditions (P<.001). Conversely, this relationship was not significant for the model consisting of older patients. Other significant factors associated with increased portal use include being female; White; married; having private insurance; and living in an area with a higher average level of educational attainment, greater medical provider density, and a lower median income.

CONCLUSIONS

Patients' use of the portal to send messages to providers was incrementally related to their number of diagnoses. As the number of chronic diagnoses increased, so did portal messaging use. Patients of all ages, particularly those living in rural areas, could benefit from the convenience and cost-effectiveness of portal communication. Health care systems and providers are encouraged to increase the use of patient portals by implementing educational interventions to promote the advantages of portal communication, particularly among patients with multimorbidity.

Implementation Fidelity of Chatbot Screening for Social Needs: Acceptability, Feasibility, Appropriateness

OBJECTIVES

Patient and provider-facing screening tools for social determinants of health have been explored in a variety of contexts; however, effective screening and resource referral remain challenging, and less is known about how patients perceive chatbots as potential social needs screening tools. We investigated patient perceptions of a chatbot for social needs screening using three implementation outcome measures: acceptability, feasibility, and appropriateness.

METHODS

We implemented a chatbot for social needs screening at one large public hospital emergency department (ED) and used concurrent triangulation to assess perceptions of the chatbot use for screening. A total of 350 ED visitors completed the social needs screening and rated the chatbot on implementation outcome measures, and 22 participants engaged in follow-up phone interviews.

RESULTS

The screened participants ranged in age from 18 to 90 years old and were diverse in race/ethnicity, education, and insurance status. Participants (n = 350) rated the chatbot as an acceptable, feasible, and appropriate way of screening. Through interviews (n = 22), participants explained that the chatbot was a responsive, private, easy to use, efficient, and comfortable channel to report social needs in the ED, but wanted more information on data use and more support in accessing resources.

CONCLUSION

In this study, we deployed a chatbot for social needs screening in a real-world context and found patients perceived the chatbot to be an acceptable, feasible, and appropriate modality for social needs screening. Findings suggest that chatbots are a promising modality for social needs screening and can successfully engage a large, diverse patient population in the ED. This is significant, as it suggests that chatbots could facilitate a screening process that ultimately connects patients to care for social needs, improving health and well-being for members of vulnerable patient populations.

Differences in Hemoglobin A1c during Pregnancy between Non-Hispanic Black versus White Women with Prepregnancy Diabetes

OBJECTIVE

The objective of this was to determine whether the change in hemoglobin A1c (HbA1c) from early to late pregnancy differs between non-Hispanic Black and White women with prepregnancy diabetes.

STUDY DESIGN

A retrospective analysis was performed from an integrated prenatal and diabetes care program from 2012 to 2016. We compared HbA1c as a continuous measure and secondarily, HbA1c <6.5%, cross-sectionally, and longitudinally in early (approximately 10 weeks) and late (approximately 31 weeks) pregnancies. Linear and logistic regression were used and adjusted for age, body mass index, White diabetes class, medication use, diabetes type, gestational age at baseline HbA1c measurement, and baseline hemoglobin.

RESULTS

Among 296 non-Hispanic Black (35%) and White pregnant women (65%) with prepregnancy diabetes (39% type 1 and 61% type 2), Black women were more likely to experience increased community-level social determinants of health as measured by the Social Vulnerability Index (SVI) and were less likely to have type 1 diabetes and have more severe diabetes versus White women (p < 0.05). Black women had higher mean HbA1c (7.8 vs. 7.4%; beta: 0.75; 95% confidence interval [CI]: 0.30-1.19) and were less likely to have HbA1c < 6.5% at 10 weeks compared with White women (24 vs. 35%; adjusted odds ratio: 0.45; 95% CI: 0.24-0.81) but not after adjusting for SVI. At 31 weeks, both groups had similar mean HbA1c (both 6.5%) and were equally as likely to have HbA1c < 6.5% (57 vs. 54%). From early to late pregnancy, Black women had a higher percentage decrease in HbA1c (1.3 vs. 0.9%; beta = 0.63; 95% CI: 0.27-0.99) and were equally as likely to have an improvement or stable HbA1C < 6.5% from 10 to 31 weeks, with both groups having a similar mean HbA1c (6.5%) at 31 weeks.

CONCLUSION

Despite experiencing greater community-level social determinants of health, Black women with pregestational diabetes had a larger reduction in HbA1c and were able to equally achieve the target of HbA1c < 6.5% by late pregnancy compared with White women as part of an integrated diabetes and prenatal care program.

KEY POINTS

· An integrated diabetes and pregnancy care program may decrease racial and ethnic disparities in glycemic control.. · Black women had a larger reduction in HbA1c versus White women.. · Black women were able to equally achieve the target of HbA1c < 6.5% by late pregnancy versus White women..

Outpatient portal use among pregnant individuals: Cross-sectional, temporal, and cluster analysis of use

Background

Outpatient portal technology can improve patient engagement. For pregnant individuals, the level of engagement could have important implications for maternal and infant outcomes.

Objective

This study: (1) cross-sectionally and temporally characterized the outpatient portal use among pregnant individuals seen at our academic medical center; and (2) identified clusters of the outpatient portal user groups based on the cross-sectional and temporal patterns of use.

Methods

We used outpatient portal server-side log files to execute a hierarchical clustering algorithm to group 7663 pregnant individuals based on proportions of outpatient portal function use. Post-hoc analyses were performed to further assess outpatient portal use on key encounter characteristics.

Results

The most frequently used functions were MyRecord (access personal health information), Visits (manage appointments), Messaging (send/receive messages), and Billing (view bills, insurance information). Median outpatient portal function use plateaued by the third trimester. Four distinct clusters were identified among all pregnant individuals: “Schedulers,” “Resulters,” “Intense Digital Engagers,” and “Average Users.” Post-hoc analyses revealed that the use of the Visits function increased and the use of the MyRecord function decreased over time among clusters.

Conclusions

Our identification of distinct cluster groups of outpatient portal users among pregnant individuals underscores the importance of avoiding the use of generalizations when describing how such patients might engage with patient-facing technologies such as an outpatient portal. These results can be used to improve user experience and training with outpatient portal functions and may educate maternal health providers on patient engagement with the outpatient portal.