Patient characteristics associated with the successful transition to virtual care: Lessons learned from the first million patients

Introduction The increased use of telehealth to maintain ambulatory care during the COVID-19 pandemic had potential to exacerbate or diminish disparities in access to care. Objective The purpose of this study was to describe patient characteristics associated with successful transition from in-person to virtual care, and video vs audio-only participation. Methods This was a retrospective analysis of electronic health record data from all patients with ambulatory visits from 1 October 2019–30 September 2020 in a large integrated health system in the Northeast USA. The outcome of interest was receipt of virtual care, and video vs audio-only participation. We matched home addresses with census-tract level area social vulnerability index (SVI) and Internet access. Among ambulatory care patients, we used logistic regression to identify characteristics associated with virtual participation. Among virtual participants, we identified characteristics associated with video vs audio-only visits. Results Among 1,241,313 patients, 528,542 (42.6%) were virtual participants. Relative to in-person only, virtual participants were older, more often English-proficient and with activated patient portal. Characteristics associated with virtual participation included patients with: only behavioural health visits, COVID patients, highest quartile of visit frequency, and multiple visit types. Characteristics associated with video participation (relative to audio-only) included being younger and patients with: only behavioural health visits, highest quartile of visit frequency, non-Hispanic black race, limited English proficiency and inactivated portal account. Discussion In our regional healthcare system, the transition to virtual care during COVID was vital for continued access to care, but substantial inequity remained. Without audio-only visits, access to care would have been even more limited for our most vulnerable patients.

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Longitudinal changes in age and race of patients with SARS-CoV-2 in a multi-hospital health system

10.1101/2021.08.16.21262016 ◽

2021 ◽

Author(s):

Ian J. Barbash ◽

Lee H. Harrison ◽

Jana L. Jacobs ◽

Faraaz Ali Shah ◽

Tomeka L. Suber ◽

...

Keyword(s):

Health System ◽

Severe Disease ◽

Patient Characteristics ◽

The United States ◽

Electronic Health Record Data ◽

Younger Patients ◽

Ethnic Subgroups ◽

Media Reports ◽

Alpha Variant ◽

The Impact

ABSTRACTBackgroundThe COVID-19 pandemic continues to affect the United States and the world. Media reports have suggested that the wave of the alpha variant in the Spring of 2021 in the US caused more cases among younger patients and racial and ethnic subgroups.ApproachWe analyzed electronic health record data from a multihospital health system to test whether younger patients accounted for more cases and more severe disease, and whether racial disparities are widening. We compared demographics, patient characteristics, and hospitalization variables for patients admitted from November 2020 through January 2021 to those admitted in March and April 2021.ResultsWe analyzed data for 37, 502 unique inpatients and outpatients at 21 hospitals from November 1, 2020 to April 30, 2021. Compared to patients from November through January, those with positive tests in March and April were younger and less likely to die. Among patients under age 50, those with positive tests in March and April were three times as likely to be hospitalized and twice as likely to require ICU admission or mechanical ventilation. Individuals identified as Black represented a greater proportion of cases and hospitalizations in March and April as compared to November through January.ConclusionsWe found that relative COVID-19 hospitalization rates for younger individuals and individuals identified as Black were rising over time. These findings have important implications for ongoing public health measures to mitigate the impact of the pandemic.

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Patient Portal Barriers and Group Differences: Cross-Sectional National Survey Study (Preprint)

10.2196/preprints.18870 ◽

2020 ◽

Author(s):

Kea Turner ◽

Alecia Clary ◽

Young-Rock Hong ◽

Amir Alishahi Tabriz ◽

Christopher M Shea

Keyword(s):

Patient Characteristics ◽

Survey Study ◽

Patient Portal ◽

Older Individuals ◽

Patient Portals ◽

Cross Sectional ◽

Number Of Patients ◽

Multiple Variable ◽

Nationally Representative ◽

National Trends

BACKGROUND Past studies examining barriers to patient portal adoption have been conducted with a small number of patients and health care settings, limiting generalizability. OBJECTIVE This study had the following two objectives: (1) to assess the prevalence of barriers to patient portal adoption among nonadopters and (2) to examine the association between nonadopter characteristics and reported barriers in a nationally representative sample. METHODS Data from this study were obtained from the 2019 Health Information National Trends Survey. We calculated descriptive statistics to determine the most prevalent barriers and conducted multiple variable logistic regression analysis to examine which characteristics were associated with the reported barriers. RESULTS The sample included 4815 individuals. Among these, 2828 individuals (58.73%) had not adopted a patient portal. Among the nonadopters (n=2828), the most prevalent barriers were patient preference for in-person communication (1810/2828, 64.00%), no perceived need for the patient portal (1385/2828, 48.97%), and lack of comfort and experience with computers (735/2828, 25.99%). Less commonly, individuals reported having no patient portal (650/2828, 22.98%), no internet access (650/2828, 22.98%), privacy concerns (594/2828, 21.00%), difficulty logging on (537/2828, 18.99%), and multiple patient portals (255/2828, 9.02%) as barriers. Men had significantly lower odds of indicating a preference for speaking directly to a provider compared with women (odds ratio [OR] 0.75, 95% CI 0.60-0.94; P=.01). Older age (OR 1.01, 95% CI 1.00-1.02; P<.001), having a chronic condition (OR 1.83, 95% CI 1.44-2.33; P<.001), and having an income lower than US $20,000 (OR 1.61, 95% CI 1.11-2.34; P=.01) were positively associated with indicating a preference for speaking directly to a provider. Hispanic individuals had significantly higher odds of indicating that they had no need for a patient portal (OR 1.59, 95% CI 1.24-2.05; P<.001) compared with non-Hispanic individuals. Older individuals (OR 1.05, 95% CI 1.04-1.06; P<.001), individuals with less than a high school diploma (OR 3.15, 95% CI 1.79-5.53; P<.001), and individuals with a household income of less than US $20,000 (OR 2.78, 95% CI 1.88-4.11; P<.001) had significantly higher odds of indicating that they were uncomfortable with a computer. CONCLUSIONS The most common barriers to patient portal adoption are preference for in-person communication, not having a need for the patient portal, and feeling uncomfortable with computers, which are barriers that are modifiable and can be intervened upon. Patient characteristics can help predict which patients are most likely to experience certain barriers to patient portal adoption. Further research is needed to tailor implementation approaches based on patients’ needs and preferences.

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112 - eVisits in Endocrinology and Metabolism: Improving Access to Care in a Tertiary Ambulatory Care Clinic

Canadian Journal of Diabetes ◽

10.1016/j.jcjd.2019.07.121 ◽

2019 ◽

Vol 43 (7) ◽

pp. S40

Author(s):

Janine Malcolm ◽

Shannon Nelson ◽

Annie Garon-Mailer ◽

Amber Mitchell ◽

Kristen RAE ◽

...

Keyword(s):

Access To Care ◽

Ambulatory Care ◽

Care Clinic ◽

Ambulatory Care Clinic

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P0816CLINICAL CHARACTERISTICS AND EGFR AND UACR DISTRIBUTION ACCORDING TO THE 2012 KDIGO CKD CLASSIFICATION: A REPORT FROM THE US DISCOVER CKD COHORT

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p0816 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Juan Jose Garcia Sanchez ◽

Juan Jesus Carrero ◽

Supriya Kumar ◽

Roberto Pecoits-Filho ◽

Glen James ◽

...

Keyword(s):

Kidney Disease ◽

Real World ◽

Patient Characteristics ◽

Study Cohort ◽

Diagnostic Code ◽

Inclusion Criteria ◽

Real World Data ◽

Electronic Health Record Data ◽

World Data ◽

Co Morbidity

Abstract Background and Aims In 2012, the Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommended categorising and prognosticating chronic kidney disease (CKD) based on estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR). Contemporary studies describing the prevalence and characteristics of patients with CKD categorised according KDIGO 2012 and how studies of new pharmacotherapies relate to these categories are scarce. One such new therapy class of key interest are the sodium glucose co-transporter 2 inhibitors (SGLT-2i), shown to delay the progression to renal failure and prevent cardiovascular/renal death in patients with CKD. We aimed to describe patient characteristics and the prevalence of CKD according to the 2012 KDIGO categories in a large real-world US cohort of patients with CKD (part A). We also describe a subset of the population according to the DAPA-CKD trial inclusion criteria (eGFR [25-75ml/min/1.73m2] and UACR [200-5000mg/g]) (part B). Method DISCOVER-CKD is an international observational study in patients with CKD. The DISCOVER-CKD retrospective US cohort of patients was extracted using real-world data from the integrated Limited Claims and Electronic Health Record data (IBM Health, Armonk, NY) and HealthVerity. Patients were aged ≥18 years, with ≥1 UACR measure. For part A, required first diagnostic code of CKD (Stages 3A, 3B, 4, 5, or ESRD) or two eGFR of <75 mL/min/1.73 m2 recorded at least 90 days apart and for part B, two measures of eGFR 25-75 mL/min/1.73 m2 recorded at least 90 days apart between 1st January 2008 and September 2018. Index date was diagnostic code or 2nd eGFR. The first UACR, recorded +/-12 months of index, was used to categorise patients. Descriptive analyses were used to summarise prevalence and patient characteristics. Results Of the overall study cohort (N=4330, 49.1% women, mean age 65.3±10.64 years), by KDIGO categories (part A): 85.7% (n=3601) had normal to mildly increased albuminuria, 11.0% (n=463) had moderately increased albuminuria and 3.3% (n=137) had severely increased albuminuria (Figure 1). 4.6% (n=193) fulfilled DAPA-CKD trial inclusion criteria (part B). In both populations, the most common comorbidities were hypertension (HTN, 73.0% for both) and type 2 diabetes (T2D, 57.6% and 56.2%, respectively). Anti-hypertensive drugs were frequently used (76.4% and 76.9%, respectively). Conclusion This study, utilising real-world data, adds to the scarcity of knowledge reporting the characteristics of patients with CKD in different eGFR and UACR strata according to the KDIGO 2012 definitions. We observed a trend in higher UACR in the group of patients with lower eGFR and report a high prevalence of T2D and HTN in the study population, demonstrating the high co-morbidity burden in patients, for whom new therapies may be beneficial.

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Ambulatory care-sensitive emergency department cases: a mixed methods approach to systemize and analyze cases in Germany

European Journal of Public Health ◽

10.1093/eurpub/ckz081 ◽

2019 ◽

Vol 29 (6) ◽

pp. 1024-1030

Author(s):

Wiebke Schuettig ◽

Leonie Sundmacher

Keyword(s):

Ambulatory Care ◽

Spatial Regression ◽

Routine Data ◽

Patient Characteristics ◽

Physician Density ◽

Policy Makers ◽

Level Data ◽

Ed Visits ◽

Future Policy ◽

Sensitive Conditions

Abstract Background Internationally, emergency departments (ED) are treating increasing numbers of patients with conditions that could have been managed appropriately in ambulatory care (AC) settings. The aim of our study was to develop the first consensus-based list of AC-sensitive conditions commonly seen in German EDs and explore predictors of these visits. Methods Our study used a Delphi survey of 30 physicians to compile a list of conditions they agreed were amenable to AC treatment. The group identified reasons why patients visit EDs instead of AC. We used the results to inform spatial regression models analysing the association of patient characteristics and attributes of AC with AC-sensitive ED visits based on 2015 district-level data. Results Our study provides a list of AC-sensitive conditions based on the German ED context. Results suggest that, up to the age of 70 years, the older the patients, the less likely they seek EDs for these conditions. Results of our regression analyses suggest that AC-sensitive ED rates were significantly higher in districts with lower physician density. Patients’ urgency perception and preferences were identified as main drivers of AC-sensitive ED visits. Conclusion Future policy measures should aim to help guide patients through the healthcare system so that they receive the best care in place that is most appropriate in terms of quality, safety and continuity of care. A list of AC-sensitive ED conditions can be used as a monitoring instrument and for further analyses of routine data to inform policy makers seeking to improve resource use and allocation.

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Patient, Provider, and System Factors Associated With Failure to Follow-Up Elevated Glucose Results in Patients Without Diagnosed Diabetes

Health Services Research and Managerial Epidemiology ◽

10.1177/2333392817721647 ◽

2017 ◽

Vol 4 ◽

pp. 233339281772164 ◽

Cited By ~ 2

Author(s):

Michael E. Bowen ◽

Zahra Merchant ◽

Kazeen Abdullah ◽

Deepa Bhat ◽

Jason Fish ◽

...

Keyword(s):

Patient Characteristics ◽

Undiagnosed Diabetes ◽

Patient Portal ◽

Factors Associated ◽

Provider Characteristics ◽

Elevated Glucose ◽

System Factors ◽

Results Management ◽

Diagnosed Diabetes

Background: Although elevated glucose values are strongly associated with undiagnosed diabetes, they are frequently overlooked. Patient, provider, and system factors associated with failure to follow-up elevated glucose values in electronic medical records (EMRs) are not well described. Methods: We conducted a chart review in a comprehensive EMR with a patient portal and results management features. Established primary care patients with no known diagnosis of diabetes and ≥ 1 glucose value >125 mg/dL were included. Follow-up failure was defined as (1) no documented comment on the glucose value or result communication to the patient within 30 days or (2) no hemoglobin A1c (HbA1c) ordered within 30 days or resulted within 12 months. Associations were examined using Wilcoxon and χ2 tests. Results: Of 150 charts reviewed, 97 met inclusion criteria. The median glucose was 133 mg/dL, and 20% of patients had multiple values >125 mg/dL. Only 36% of elevated glucose values were followed up. No associations were observed between patient characteristics, diabetes risk factors, or provider characteristics and follow-up failures. Automated flagging of glucose values ≥140 mg/dL by highlighting them red in the EMR was not associated with improved follow-up (46% vs 32%; P = .19). Even when follow-up occurred (n = 35), only 31% completed gold standard diabetes testing (HbA1c) within 12 months. Of the resulted HbA1c tests (n = 11), 55% were in the prediabetes range (5.7%-6.4%). Conclusions: Two-thirds of elevated glucose values were not followed up, despite EMR features facilitating results management. Greater understanding of the results management process and improved EMR functionalities to support results management are needed.

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Factors Affecting Treatment with Life-Saving Interventions, Computed Tomography Scans and Specialist Consultations

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17082914 ◽

2020 ◽

Vol 17 (8) ◽

pp. 2914

Author(s):

Chu-Chieh Chen ◽

Chin-Yi Chen ◽

Ming-Chung Ko ◽

Yi-Chun Chien ◽

Emily Chia-Yu Su ◽

...

Keyword(s):

Computed Tomography ◽

Health Status ◽

Ambulatory Care ◽

Patient Characteristics ◽

Multivariate Logistic Regression Model ◽

Medical Institutions ◽

Patient Health Status ◽

Life Saving ◽

Patient Health ◽

The Impact

Background: Emergency treatments determined by emergency physicians may affect mortality and patient satisfaction. This paper attempts to examine the impact of patient characteristics, health status, the accredited level of hospitals, and triaged levels on the following emergency treatments: immediate life-saving interventions (LSIs), computed tomography (CT) scans, and specialist consultations (SCs). Methods: A multivariate logistic regression model was employed to analyze the impact of patient characteristics, including sex, age, income and the urbanization degree of the patient’s residence; patient health status, including records of hospitalization and the number of instances of ambulatory care in the previous year; the Charlson Comorbidity Index (CCI) score; the accredited level of hospitals; and the triaged level of emergency treatments. Results: All the patient characteristics were found to impact receiving LSI, CT and SC, except for income. Furthermore, a better health status was associated with a decreased probability of receiving LSI, CT and SC, but the number of instances of ambulatory care was not found to have a significant impact on receiving CT or SC. This study also found no evidence to support impact of CCI on SC. Hospitals with higher accredited levels were associated with a greater chance of patients receiving emergency treatments of LSI, CT and SC. A higher assigned severity (lower triaged level) led to an increased probability of receiving CT and SC. In terms of LSI, patients assigned to level 4 were found to have a lower chance of treatment than those assigned to level 5. Conclusions: This study found that several patient characteristics, patient health status, the accredited level of medical institutions and the triaged level, were associated with a higher likelihood of receiving emergency treatments. This study suggests that the inequality of medical resources among medical institutions with different accredited levels may yield a crowding-out effect.

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Access to Care and the Incidence of Endstage Renal Disease Due to Systemic Lupus Erythematosus

The Journal of Rheumatology ◽

10.3899/jrheum.091199 ◽

2010 ◽

Vol 37 (6) ◽

pp. 1158-1163 ◽

Cited By ~ 29

Author(s):

MICHAEL M. WARD

Keyword(s):

Systemic Lupus Erythematosus ◽

Access To Care ◽

Ambulatory Care ◽

Lupus Erythematosus ◽

Ambulatory Care Sensitive Conditions ◽

Systemic Lupus ◽

Endstage Renal Disease ◽

Zip Code ◽

Ambulatory Care Sensitive ◽

Sensitive Conditions

Objective.Persons with low socioeconomic status have an increased risk of endstage renal disease (ESRD) due to systemic lupus erythematosus (SLE), possibly because of limited access to care. We examined if the incidence of ESRD due to SLE was higher in geographic areas with poorer access to care.Methods.In this population-based ecological study, we tested associations between the incidence of ESRD due to SLE and the proportion of hospitalizations with no insurance, Medicaid or managed care insurance, residence in a primary care-provider shortage area or rural area, and rate of hospitalizations for ambulatory care-sensitive conditions, by ZIP code in California in 1999–2004.Results.The incidence of ESRD due to SLE was higher in ZIP codes with higher proportions of hospitalizations with no insurance (r = 0.22, p < 0.0001) or Medicaid (r = 0.21, p < 0.0001), and in ZIP codes with higher rates of hospitalizations for ambulatory care-sensitive conditions (r = 0.23, p < 0.0001). In multivariate analyses, incidences were higher in ZIP codes with higher proportions of hospitalizations with Medicaid (p < 0.0001) and higher rates of hospitalizations for ambulatory care-sensitive conditions (p = 0.06), independent of the socioeconomic status of the ZIP code residents.Conclusion.The incidence of ESRD due to SLE is higher in areas with higher proportions of residents who have public insurance and higher rates of avoidable hospitalizations, suggesting that limited access to care may contribute to this complication of SLE.

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Disparities in Pediatric Patient Portal Activation and Feature Use

JAMIA Open ◽

10.1093/jamiaopen/ooab086 ◽

2021 ◽

Vol 4 (3) ◽

Author(s):

Jennifer H LeLaurin ◽

Oliver T Nguyen ◽

Lindsay A Thompson ◽

Jaclyn Hall ◽

Jiang Bian ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

White Female ◽

Patient Portal ◽

Patient Portals ◽

Electronic Health Record Data ◽

Factors Associated ◽

Academic Medical ◽

Vulnerable Individual ◽

Records Access

Abstract Objective Disparities in adult patient portal adoption are well-documented; however, less is known about disparities in portal adoption in pediatrics. This study examines the prevalence and factors associated with patient portal activation and the use of specific portal features in general pediatrics. Materials and methods We analyzed electronic health record data from 2012 to 2020 in a large academic medical center that offers both parent and adolescent portals. We summarized portal activation and use of select portal features (messaging, records access and management, appointment management, visit/admissions summaries, and interactive feature use). We used logistic regression to model factors associated with patient portal activation among all patients along with feature use and frequent feature use among ever users (ie, ≥1 portal use). Results Among 52 713 unique patients, 39% had activated the patient portal, including 36% of patients aged 0–11, 41% of patients aged 12–17, and 62% of patients aged 18–21 years. Among activated accounts, ever use of specific features ranged from 28% for visit/admission summaries to 92% for records access and management. Adjusted analyses showed patients with activated accounts were more likely to be adolescents or young adults, white, female, privately insured, and less socioeconomically vulnerable. Individual feature use among ever users generally followed the same pattern. Conclusions Our findings demonstrate that important disparities persist in portal adoption in pediatric populations, highlighting the need for strategies to promote equitable access to patient portals.

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Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocaa284 ◽

2020 ◽

Author(s):

Jacqueline M Ferguson ◽

Josephine Jacobs ◽

Maria Yefimova ◽

Liberty Greene ◽

Leonie Heyworth ◽

...

Keyword(s):

Service Use ◽

Linear Models ◽

Patient Characteristics ◽

Veterans Affairs ◽

Veterans Health ◽

Access Barriers ◽

Health Administration ◽

Homeless Veterans ◽

Virtual Care ◽

To Receive

Abstract Objectives To describe the shift from in-person to virtual care within Veterans Affairs (VA) during the early phase of the COVID-19 pandemic and to identify at-risk patient populations who require greater resources to overcome access barriers to virtual care. Materials and Methods Outpatient encounters (N = 42 916 349) were categorized by care type (eg, primary, mental health, etc) and delivery method (eg, in-person, video). For 5 400 878 Veterans, we used generalized linear models to identify patient sociodemographic and clinical characteristics associated with: 1) use of virtual (phone or video) care versus no virtual care and 2) use of video care versus no video care between March 11, 2020 and June 6, 2020. Results By June, 58% of VA care was provided virtually compared to only 14% prior. Patients with lower income, higher disability, and more chronic conditions were more likely to receive virtual care during the pandemic. Yet, Veterans aged 45–64 and 65+ were less likely to use video care compared to those aged 18–44 (aRR 0.80 [95% confidence interval (CI) 0.79, 0.82] and 0.50 [95% CI 0.48, 0.52], respectively). Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban (0.88 [95% CI 0.86, 0.90]) and nonhomeless Veterans (0.89 [95% CI 0.86, 0.92]). Discussion Veterans with high clinical or social need had higher likelihood of virtual service use early in the COVID-19 pandemic; however, older, homeless, and rural Veterans were less likely to have video visits, raising concerns for access barriers. Conclusions and Relevance While virtual care may expand access, access barriers must be addressed to avoid exacerbating disparities.

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