Use of a web portal among adult clinic patients seen for type 2 diabetes mellitus
Introduction
Over 30 million Americans had diabetes in 2015 and the number is expected to increase over time (1). Persons with diabetes have an increased risk of macrovascular and microvascular complications (2). Good glycemic control is associated with reduced morbidity and mortality, but almost half of patients with type 2 diabetes do not meet recommended targets for glycemic control, or cholesterol control, or blood pressure control (3-5).
To manage side effects, monitor blood test results, and screen for potential complications, type 2 diabetes requires effective communication between providers and patients and patient self-management (6). Studies have shown that increasing patients’ knowledge about their risk factors can lead to improved clinical outcomes (7,8). Moreover, evidence shows that fostering a collaborative relationship between patients and their health care providers can also improve clinical outcomes (9,10).
Efforts at health care reform and continued advances in information technologies have increased interest among providers and researchers in patient web portals. Stakeholders view patient portals, and parallel advances in eHealth such as personal health records and electronic medical records (EMRs), as an opportunity to leverage information technology to support patient self-management and improve patient-provider communication between office visits (11,12). The introduction of web-based, patient-centered health care information systems linked to a patient’s EMR (patient web portals) constitute an important development in diabetes care.
The goal of the current feasibility study was to determine the number of adult patients seen for type 2 diabetes at a large medical center in the U.S. and to examine whether they had registered for the patient web portal according to age, sex, race and Hispanic ethnicity, service (General Internal Medicine, Endocrinology), and calendar year (all of 2016, vs. January to August of 2017).
Methods
The current study was conducted as “preparatory to research” in support of a grant application for a larger and more detailed proposed study. Prior to a review of computerized patient records, a determination was made by the Augusta University Institutional Review Board (IRB) that the study was exempt from IRB review. Informed consent was not required for a review of existing patient records that did include any personally identifying information. EMRs were reviewed including web portal registration by patients treated for type 2 diabetes (ICD-10 codes E-11, etc.). The patients were seen in General Internal Medicine and Endocrinology clinics at a large academic health center. De-identified number of patients seen for diabetes were examined by age categories, sex, race and Hispanic ethnicity, and era (Table 1). EMRs for patients seen in Family Medicine clinics were not abstracted because a different EMRs system is in use. Odds ratios (OR), 95% confidence intervals (CI), and P values were obtained using Epi Info version 7.2.0.1. An approximate chi-square test was used to test for interaction on an additive scale (13). Multivariate analysis was carried out using logistic regression methods to determine adjusted odds ratios and assess statistical significance (14). In this regression method, the logarithmic odds of disease is modeled as a linear function of explanatory variables and maximum likelihood estimates of their beta coefficients.
Table 1
| Variables | Registered for VIP, N [%] | Not registered, N [%] |
|---|---|---|
| Service | ||
| Internal medicine | 205 [46] | 245 [54] |
| Endocrinology | 250 [26] | 701 [74] |
| Total | 455 [32] | 946 [68] |
| Age (years) | ||
| 18–25 | 5 [17] | 24 [83] |
| 26–30 | 19 [30] | 44 [70] |
| 31–35 | 15 [38] | 25 [63] |
| 36–40 | 30 [39] | 47 [61] |
| 41–45 | 40 [40] | 60 [60] |
| 46–50 | 51 [39] | 79 [61] |
| 51–55 | 59 [37] | 100 [63] |
| 56–60 | 41 [24] | 132 [76] |
| 61–65 | 86 [39] | 133 [61] |
| 66+ | 109 [27] | 302 [73] |
| Sex | ||
| Male | 163 [30] | 388 [70] |
| Female | 292 [34] | 558 [66] |
| Race | ||
| White | 308 [40] | 457 [60] |
| Black | 113 [21] | 421 [79] |
| Hispanic | 9 [27] | 24 [73] |
| Other | 25 [36] | 44 [64] |
| Year | ||
| 2016 | 302 [33] | 624 [67] |
| 2017 (Jan–Aug) | 153 [32] | 322 [68] |
*, the above table does not include diabetes patients followed at Family Medicine clinics or at two satellite General Internal Medicine clinics (West Wheeler Internal Medicine Clinic and the Continuity Clinic). VIP, Virtually Informed Patient.
Results
A total of 1,401 adult patients with type 2 diabetes mellitus were seen in General Internal Medicine and Endocrinology outpatient clinics between January 2016 and August 2017. Of the 1,401 patients, less than one third (32%) had registered for the web portal (Table 1). Women with diabetes were more likely to have registered for the patient web portal than men (OR =1.25; 95% CI, 0.99–1.57; P<0.063) although the association was not statistically significant. Black patients were less likely to have registered for the web portal than whites (OR =0.40; 95% CI, 0.31–0.51; P<0.001). Diabetic patients who were 18 to 25 years of age were less likely to have registered for the web portal, along with those who were 56 to 60 and >66 years of age.
Table 2 shows the relationship between race and sex. There was no indication that race modified the relationship between sex and patient web portal registration (Table 2). White women with type 2 diabetes mellitus were more likely to have registered for the web portal than Black males (OR =4.14, P<0.001). White men with type 2 diabetes mellitus were more likely to have registered for the web portal than Black men (OR =2.73, P<0.001).
Table 2
| Demographic variables | Registered for VIP, N [%] | Not registered, N [%] | OR | P value |
|---|---|---|---|---|
| White female | 192 [46] | 240 [27] | 4.14 | 0.000 |
| Black female | 85 [20] | 277 [32] | 1.58 | 0.058 |
| White male | 115 [27] | 217 [25] | 2.73 | 0.000 |
| Black male | 28 [7] | 144 [16] | 1.00† | – |
| Total | 421 [100] | 878 [100] | – | – |
*, the above table does not include diabetes patients followed at Family Medicine clinics or at two satellite General Internal Medicine clinics (West Wheeler Internal Medicine Clinic and the Continuity Clinic). Because the numbers of patients were small, those whose race was “Other” were excluded from this analysis along with those who were Hispanic. Chi-square test for additive interaction not significant (P>0.05); †, referent category. OR, odds ratios; VIP, Virtually Informed Patient.
Table 3 summarizes results from multivariate analysis using logistic regression. A statistically significant, independent association was observed between patient web portal registration and General Internal Medicine clinic vs. Endocrinology clinic (OR =2.96, P<0.001). Inverse associations were observed with age
Table 3
| Covariates | OR | P value | 95% CI |
|---|---|---|---|
| Service | |||
| Endocrinology | 1.00† | – | – |
| Internal medicine | 2.96 | <0.001 | 2.27–3.85 |
| Age (years) | |||
| 18–25 | 1.00† | – | – |
| 26–30 | 2.04 | 0.215 | 0.66–6.26 |
| 31–35 | 2.87 | 0.080 | 0.88–9.37 |
| 36–40 | 2.85 | 0.060 | 0.95–8.48 |
| 41–45 | 3.15 | 0.035 | 1.09–9.15 |
| 46–50 | 2.74 | 0.059 | 0.96–7.81 |
| 51–55 | 2.35 | 0.106 | 0.83–6.63 |
| 56–60 | 1.46 | 0.479 | 0.51–4.14 |
| 61–65 | 2.49 | 0.079 | 0.90–6.92 |
| 66+ | 1.32 | 0.593 | 0.48–3.61 |
| Sex | |||
| Male | 1.00† | – | – |
| Female | 0.71 | 0.006 | 0.55–0.91 |
| Race/ethnicity | |||
| White | 1.00† | – | – |
| Black | 0.33 | <0.001 | 0.25–0.43 |
| Hispanic | 0.52 | 0.110 | 0.23–1.16 |
| Other | 0.72 | 0.226 | 0.42–1.23 |
| Year | |||
| 2016 | <0.001 | – | – |
| 2017 | 0.15 | 0.297 | 0.89–1.49 |
*, the above table does not include diabetes patients followed at Family Medicine clinics or at two satellite General Internal Medicine clinics (West Wheeler Internal Medicine Clinic and the Continuity Clinic); †, referent category. OR, odds ratios.
Conclusions
The results of this feasibility study indicate that less than one-third of adult clinic patients with type 2 diabetes mellitus have registered for the VIP web portal and that registration rates are particularly low among patients who are Black, male, or <26 years of age, and those seen in endocrinology clinics. Based upon these findings, we are planning a larger and more detailed study to determine why many patients do not use the web portal and to examine the effectiveness of the web portal in improving glycemic control among adult clinic patients with type 2 diabetes mellitus. A goal of the planned study, which is dependent upon receipt of extramural funding, is to determine the specific portal features that may improve quality of care or glycemic control (e.g., patient-provider secure messaging) and to examine the effectiveness of an intervention to increase use of the patient web portal by diabetic patients.
The inverse association with Black race may be due to uncontrolled confounding by health literacy or computer literacy (15,16). In this initial feasibility study, no information was available about the computer literacy or health literacy of the adult patients with type 2 diabetes mellitus. Limited health literacy is relatively common among patients with type 2 diabetes and is likely to contribute to poorer diabetes outcomes (15-18). Studies indicate that patients with lower health literacy are less likely to use web portals to help manage a chronic illness (12,15). Patients with lower health literacy or computer literacy may have difficulty learning how to use a web portal or they may have difficulty navigating a portal. Educational outreach efforts for potential web portal users may be helpful in overcoming these perceived barriers.
A limited number of studies have examined the use of web portals tethered to EMRs for diabetes management (19). Although results-to-date have been mixed, results from prior studies suggest that secure messaging between adult diabetic patients and their clinician is associated with improved glycemic control (19). Improvements in low density lipoprotein (LDL) cholesterol and blood pressure have also been observed in some studies of web portals used by patients with diabetes and hypertension (6). The specific portal features that may impact quality of care or improve glycemic control (e.g., patient-provider secure messaging, online access to lab test results or instructions, other patient supports) has not been clearly distinguished by studies completed to date. Results from prior studies indicate that many diabetic patients do not take advantage of web portal features such as secure messaging, when offered, perhaps because of a lack of internet access or to a lack of experience in navigating web portal resources (16).
With respect to limitations, the current study did not examine the specific reasons that patients with diabetes had registered for the web portal or whether they used it over time. Future studies should examine whether patients who have registered for the web portal use it for secure messaging and whether they are active secure message users or whether they only rarely send secure messages to their provider. A further limitation is that the current study was cross-sectional in nature and lacked information about the temporal relationship between treatment for diabetes and patient web portal registration. The current study examined prevalent cases of diabetes which could have been diagnosed recently or in the past.
Additional research is needed to identify specific portal design features that improve glycemic control and interventions that are effective in increasing use of this patient web portals among diabetic patients, especially among Black patients and among patients with low health literacy or computer literacy.
Acknowledgments
The authors are grateful to Lindsey Kitchen for providing assistance with the abstraction of information from electronic medical records.
Funding: None.
Footnote
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jhmhp.2017.12.04). SSC serve as an unpaid Associate Editor of Journal of Hospital Management and Health Policy. The other authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The Augusta University Institutional Review Board (IRB) determined that the study was exempt from IRB review. Informed consent was not required for a review of existing patient records that did include any personally identifying information.
Disclaimer: The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Coughlin SS, Heboyan V, Williams LB, Hatzigeorgiou C. Use of a web portal among adult clinic patients seen for type 2 diabetes mellitus. J Hosp Manag Health Policy 2018;2:1.
