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Powell DS, Wu MJ, Nothelle S, Gleason K, Smith JM, Peereboom D, Oh ES, Reed NS, Wolff JL. Documentation of hearing difficulty by providers amidst cognitive concerns: A study of the Medicare Annual Wellness Visit. J Am Geriatr Soc 2024. [PMID: 39192459 DOI: 10.1111/jgs.19145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 08/29/2024]
Affiliation(s)
- Danielle S Powell
- Department of Speech and Hearing Sciences, University of Maryland, College Park, Maryland, USA
| | - M J Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Gleason
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jamie M Smith
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Danielle Peereboom
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas S Reed
- Optimal Aging Institute, NYU Grossman School of Medicine, New York, New York, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Gleason KT, Powell D, DeGennaro AP, Wu MMJ, Zhang T, Wolff JL. Patient portal messages to support an age-friendly health system for persons with dementia. J Am Geriatr Soc 2024; 72:2140-2147. [PMID: 38411982 PMCID: PMC11226382 DOI: 10.1111/jgs.18841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/25/2024] [Accepted: 02/09/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Patient portal secure messaging can support age-friendly dementia care, yet little is known about care partner use of the portal and how message concerns relate to age-friendly issues. METHODS We conducted a two-part observational study. We first assessed the feasibility of automating care partner identification from patient portal messages by developing and testing a natural language processing (NLP) rule-based classification system from portal messages of 1973 unique patients 65 and older. Second, two independent reviewers manually coded a randomly selected sample of portal messages for 987 persons with dementia to identify the frequency of expressed needs from the 4M domains of an Age-Friendly Health System (medications, mentation, mobility, and what matters). RESULTS A total of 267 (13.53%) of 1973 messages sent from older adults' portal accounts were identified through manual coding as sent by a nonpatient author. The NLP model performance to identify nonpatient authors demonstrated an AUC of 0.90. Most messages sent from the accounts of persons with dementia contained content relevant to the 4Ms (60%, 601/987), with the breakdown as follows: medications-36% (357/987), mobility-10% (101/987), mentation-16% (153/987), and what matters (aligning care with specific health goals and care preferences)-21%, 207/987. CONCLUSIONS Patient portal messaging offers an avenue to identify care partners and meet the informational needs of persons with dementia and their care partners.
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Affiliation(s)
| | - Danielle Powell
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Mingche MJ Wu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Talan Zhang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Wolff JL, Wec A, Peereboom D, Gleason KT, Amjad H, Burgdorf JG, Cassidy J, DesRoches CM, Fabius CD, Green AR, Lin CT, Nothelle SK, Powell DS, Riffin CA, Smith J, Lum HD. Care partners and consumer health information technology: A framework to guide systems-level initiatives in support of digital health equity. Learn Health Syst 2024; 8:e10408. [PMID: 38883870 PMCID: PMC11176584 DOI: 10.1002/lrh2.10408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Consumer-oriented health information technologies (CHIT) such as the patient portal have a growing role in care delivery redesign initiatives such as the Learning Health System. Care partners commonly navigate CHIT demands alongside persons with complex health and social needs, but their role is not well specified. Methods We assemble evidence and concepts from the literature describing interpersonal communication, relational coordination theory, and systems-thinking to develop an integrative framework describing the care partner's role in applied CHIT innovations. Our framework describes pathways through which systematic engagement of the care partner affects longitudinal work processes and multi-level outcomes relevant to Learning Health Systems. Results Our framework is grounded in relational coordination, an emerging theory for understanding the dynamics of coordinating work that emphasizes role-based relationships and communication, and the Systems Engineering Initiative for Patient Safety (SEIPS) model. Cross-cutting work systems geared toward explicit and purposeful support of the care partner role through CHIT may advance work processes by promoting frequent, timely, accurate, problem-solving communication, reinforced by shared goals, shared knowledge, and mutual respect between patients, care partners, and care team. We further contend that systematic engagement of the care partner in longitudinal work processes exerts beneficial effects on care delivery experiences and efficiencies at both individual and organizational levels. We discuss the utility of our framework through the lens of an illustrative case study involving patient portal-mediated pre-visit agenda setting. Conclusions Our framework can be used to guide applied embedded CHIT interventions that support the care partner role and bring value to Learning Health Systems through advancing digital health equity, improving user experiences, and driving efficiencies through improved coordination within complex work systems.
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Affiliation(s)
- Jennifer L Wolff
- Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Aleksandra Wec
- Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Danielle Peereboom
- Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Kelly T Gleason
- Johns Hopkins University School of Nursing Baltimore Maryland USA
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Julia G Burgdorf
- Center for Home Care Policy & Research Visiting Nurse Service of New York New York New York USA
| | - Jessica Cassidy
- School of Social Work University of Texas at Arlington Arlington Texas USA
| | | | - Chanee D Fabius
- Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - C T Lin
- University of Colorado Aurora Colorado USA
| | - Stephanie K Nothelle
- Division of Geriatric Medicine and Gerontology Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Danielle S Powell
- Department of Hearing & Speech Sciences University of Maryland College Park Maryland USA
| | - Catherine A Riffin
- Division of Geriatrics and Palliative Medicine Weill Cornell Medical Center New York New York USA
| | - Jamie Smith
- Johns Hopkins School of Nursing Baltimore Maryland USA
| | - Hillary D Lum
- Division of Geriatric Medicine University of Colorado School of Medicine Aurora Colorado USA
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Bartels SJ, Reynolds CF. Reverse Innovation, Partnerships, and The Role of Academic Health Systems in Creating a Sustainable Geriatric Health Care System. Am J Geriatr Psychiatry 2024; 32:405-408. [PMID: 38503540 DOI: 10.1016/j.jagp.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Affiliation(s)
- Stephen J Bartels
- James J. and Jean H. Mongan Chair in Health Policy and Community Health, Director of Mongan Institute, Massachusetts General Hospital, Professor of Medicine, Harvard Medical School..
| | - Charles F Reynolds
- Distinguished Professor of Psychiatry and UPMC Endowed Professor in Geriatric Psychiatry emeritus, University of Pittsburgh School of Medicine, Editor, American Journal of Geriatric Psychiatry
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Powell DS, Wu MMJ, Nothelle S, Gleason K, Oh E, Lum HD, Reed NS, Wolff JL. The Annual Wellness Visit Health Risk Assessment: Potential of Patient Portal-Based Completion and Patient-Oriented Education and Support. Innov Aging 2024; 8:igae023. [PMID: 38618518 PMCID: PMC11010311 DOI: 10.1093/geroni/igae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Indexed: 04/16/2024] Open
Abstract
Background and Objectives Patient portals are secure online platforms that allow patients to perform electronic health management tasks and engage in bidirectional information exchange with their care team. Some health systems administer Medicare Annual Wellness Visit (AWV) health risk assessments through the patient portal. Scalable opportunities from portal-based administration of risk assessments are not well understood. Our objective is 2-fold-to understand who receives vs misses an AWV and health risk assessment and explore who might be missed with portal-based administration. Research Design and Methods This is an observational study of electronic medical record and patient portal data (10/03/2021-10/02/2022) for 12 756 primary care patients 66+ years from a large academic health system. Results Two-thirds (n = 8420) of older primary care patients incurred an AWV; 81.0% of whom were active portal users. Older adults who were active portal users were more likely to incur AWV than those who were not, though portal use was high in both groups (81.0% with AWV vs 76.8% without; p < .001). Frequently affirmative health risk assessment categories included falls/balance concerns (44.2%), lack of a documented advanced directive (42.3%), sedentary behaviors (39.9%), and incontinence (35.1%). Mean number of portal messages over the 12-month observation period varied from 7.2 among older adults affirmative responses to concerns about safety at home to 13.8 for older adults who reported difficulty completing activities of daily living. Portal messaging varied more than 2-fold across affirmative health risk categories and were marginally higher with greater number affirmative (mean = 13.8 messages/year no risks; 19.6 messages/year 10+ risks). Discussion and Implications Most older adults were active portal users-a group more likely to have incurred a billed AWV. Efforts to integrate AWV risk assessments in the patient portal may streamline administration and scalability for dissemination of tailored electronically mediated preventive care but must attend to equity issues.
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Affiliation(s)
- Danielle S Powell
- Department of Hearing and Speech Sciences, University of Maryland, College Park, Maryland, USA
| | - Mingche M J Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stephanie Nothelle
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Gleason
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Esther Oh
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicholas S Reed
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bratches RWR, Wall JA, Puga F, Pilonieta G, Jablonski R, Bakitas M, Geldmacher DS, Odom JN. Patient Portal Use Among Family Caregivers of Individuals With Dementia and Cancer: Regression Analysis From the National Study of Caregiving. JMIR Aging 2023; 6:e44166. [PMID: 38235767 PMCID: PMC10811454 DOI: 10.2196/44166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 08/10/2023] [Accepted: 08/25/2023] [Indexed: 01/19/2024] Open
Abstract
Background Family caregivers are often inexperienced and require information from clinic visits to effectively provide care for patients. Despite reported deficiencies, 68% of health systems facilitate sharing information with family caregivers through the patient portal. The patient portal is especially critical in the context of serious illnesses, like advanced cancer and dementia, where caregiving is intense and informational needs change over the trajectory of disease progression. Objective The objective of our study was to analyze a large, nationally representative sample of family caregivers from the National Study of Caregiving (NSOC) to determine individual characteristics and demographic factors associated with patient portal use among family caregivers of persons living with dementia and those living with cancer. Methods We conducted a secondary data analysis using data from the 2020 NSOC sample of family caregivers linked to National Health and Aging Trends Study. Weighted regression analysis by condition (ie, dementia or cancer) was used to examine associations between family caregiver use of the patient portal and demographic variables, including age, race or ethnicity, gender, employment status, caregiver health, education, and religiosity. Results A total of 462 participants (representing 4,589,844 weighted responses) were included in our analysis. In the fully adjusted regression model for caregivers of persons living with dementia, Hispanic ethnicity was associated with higher odds of patient portal use (OR: 2.81, 95% CI 1.05-7.57; P=.04), whereas qualification lower than a college degree was associated with lower odds of patient portal use by family caregiver (OR 0.36, 95% CI 0.18-0.71; P<.001. In the fully adjusted regression model for caregivers of persons living with cancer, no variables were found to be statistically significantly associated with patient portal use at the .05 level. Conclusions In our analysis of NSOC survey data, we found differences between how dementia and cancer caregivers access the patient portal. As the patient portal is a common method of connecting caregivers with information from clinic visits, future research should focus on understanding how the portal is used by the groups we have identified, and why.
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Affiliation(s)
- Reed W R Bratches
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Jaclyn A Wall
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Frank Puga
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Giovanna Pilonieta
- Department of Neurology, University of Alabama at Birmingham, BirminghamAL, United States
| | - Rita Jablonski
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
| | - David S Geldmacher
- Department of Neurology, University of Alabama at Birmingham, BirminghamAL, United States
| | - J Nicholas Odom
- School of Nursing, University of Alabama at Birmingham, BirminghamAL, United States
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Gleason KT, Wu MMJ, Wec A, Powell DS, Zhang T, Gamper MJ, Green AR, Nothelle S, Amjad H, Wolff JL. Use of the patient portal among older adults with diagnosed dementia and their care partners. Alzheimers Dement 2023; 19:5663-5671. [PMID: 37354066 PMCID: PMC10808947 DOI: 10.1002/alz.13354] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/28/2023] [Accepted: 05/29/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Care partners are at the forefront of dementia care, yet little is known about patient portal use in the context of dementia diagnosis. METHODS We conducted an observational cohort study of date/time-stamped patient portal use for a 5-year period (October 3, 2017-October 2, 2022) at an academic health system. The cohort consisted of 3170 patients ages 65+ with diagnosed dementia with 2+ visits within 24 months. Message authorship was determined by manual review of 970 threads involving 3065 messages for 279 patients. RESULTS Most (71.20%) older adults with diagnosed dementia were registered portal users but far fewer (10.41%) had a registered care partner with shared access. Care partners authored most (612/970, 63.09%) message threads, overwhelmingly using patient identity credentials (271/279, 97.13%). DISCUSSION The patient portal is used by persons with dementia and their care partners. Organizational efforts that facilitate shared access may benefit the support of persons with dementia and their care partners. Highlights Patient portal registration and use has been increasing among persons with diagnosed dementia. Two thirds of secure messages from portal accounts of patients with diagnosed dementia were identified as being authored by care partners, primarily using patient login credentials. Care partners who accessed the patient portal using their own identity credentials through shared access demonstrate similar levels of activity to patients without dementia. Organizational initiatives should recognize and support the needs of persons with dementia and their care partners by encouraging awareness, registration, and use of proper identity credentials, including shared, or proxy, portal access.
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Affiliation(s)
- Kelly T. Gleason
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Mingche M. J. Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aleksandra Wec
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Danielle S. Powell
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Talan Zhang
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary Jo Gamper
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Ariel R. Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L. Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Dukhanin V, Wolff JL, Salmi L, Harcourt K, Wachenheim D, Byock I, Gonzales MJ, Niehus D, Parshley M, Reay C, Epstein S, Mohile S, Farrell TW, Supiano MA, Jajodia A, DesRoches CM. Co-Designing an Initiative to Increase Shared Access to Older Adults' Patient Portals: Stakeholder Engagement. J Med Internet Res 2023; 25:e46146. [PMID: 37991827 PMCID: PMC10701652 DOI: 10.2196/46146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/02/2023] [Accepted: 07/22/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The patient portal is a widely available secure digital platform offered by care delivery organizations that enables patients to communicate electronically with clinicians and manage their care. Many organizations allow patients to authorize family members or friends-"care partners"-to share access to patient portal accounts, thus enabling care partners to receive their own identity credentials. Shared access facilitates trilateral information exchange among patients, clinicians, and care partners; however, uptake and awareness of this functionality are limited. OBJECTIVE We partnered with 3 health care organizations to co-design an initiative that aimed to increase shared access registration and use and that can be implemented using existing patient portals. METHODS In 2020, we undertook a rigorous selection process to identify 3 geographically diverse health care organizations that had engaged medical informatics teams and clinical champions within service delivery lines caring for older adults. We prioritized selecting organizations that serve racially and socioeconomically diverse populations and possess sophisticated reporting capabilities, a stable patient portal platform, a sufficient volume of older adult patients, and active patient and family advisory councils. Along with patients and care partners, clinicians, staff, and other stakeholders, the study team co-designed an initiative to increase the uptake of shared access guided by either an iterative, human-centered design process or rapid assessment procedures of stakeholders' inputs. RESULTS Between February 2020 and April 2022, 73 stakeholder engagements were conducted with patients and care partners, clinicians and clinic staff, medical informatics teams, marketing and communications staff, and administrators, as well as with funders and thought leaders. We collected insights regarding (1) barriers to awareness, registration, and use of shared access; (2) features of consumer-facing educational materials to address identified barriers; (3) features of clinician- and staff-facing materials to address identified barriers; and (4) approaches to fit the initiative into current workflows. Using these inputs iteratively via a human-centered design process, we produced brochures and posters, co-designed organization-specific web pages detailing shared access registration processes, and developed clinician and staff talking points about shared access and staff tip sheets that outline shared access registration steps. Educational materials emphasized the slogan "People remember less than half of what their doctors say," which was selected from 9 candidate alternatives as resonating best with the full range of the initiative's stakeholders. The materials were accompanied by implementation toolkits specifying and reinforcing workflows involving both in-person and telehealth visits. CONCLUSIONS Meaningful and authentic stakeholder engagement allowed our deliberate, iterative, and human-centered co-design aimed at increasing the use of shared access. Our initiative has been launched as a part of a 12-month demonstration that will include quantitative and qualitative analysis of registration and use of shared access. Educational materials are publicly available at Coalition for Care Partners.
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Affiliation(s)
- Vadim Dukhanin
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Liz Salmi
- OpenNotes, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Kendall Harcourt
- OpenNotes, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Deborah Wachenheim
- OpenNotes, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Ira Byock
- The Institute for Human Caring at Providence, Gardena, CA, United States
| | - Matthew J Gonzales
- The Institute for Human Caring at Providence, Gardena, CA, United States
| | - Doug Niehus
- Providence Medical Group, Portland, OR, United States
| | | | - Caroline Reay
- Providence Medical Group, Portland, OR, United States
| | - Sara Epstein
- The Institute for Human Caring at Providence, Gardena, CA, United States
| | - Supriya Mohile
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Timothy W Farrell
- Division of Geriatrics, Spencer Fox Eccles School of Medicine and the Center on Aging, University of Utah, Salt Lake City, UT, United States
- Salt Lake City Geriatric Research, Education, and Clinical Center, Veterans Affairs, Salt Lake City, UT, United States
| | - Mark A Supiano
- Division of Geriatrics, Spencer Fox Eccles School of Medicine and the Center on Aging, University of Utah, Salt Lake City, UT, United States
| | - Anushka Jajodia
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
| | - Catherine M DesRoches
- OpenNotes, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
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Gabbard JL, Carpenter JG, Ernecoff NC, Mournighan K, Cornea I, McKone M, Hanson LC. Evaluating the pragmatic characteristics of advance care planning outcome measures in dementia clinical trials: A scoping review. J Am Geriatr Soc 2023; 71:3595-3608. [PMID: 37439456 PMCID: PMC10787044 DOI: 10.1111/jgs.18495] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Advance care planning (ACP) is a process that involves discussing a person's goals, values, and preferences; it is particularly important for persons living with dementia (PLWD) given that dementia is incurable and progressive. To ensure results that will impact real-world practices, ACP outcome measures must be psychometrically strong, meaningful to key partners, and pragmatic to collect. Therefore, we conducted a scoping review of outcome measures utilized in ACP randomized controlled clinical trials (RCTs) enrolling PLWD or their care partners and evaluated their pragmatic characteristics. METHODS We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for peer-reviewed ACP RCTs enrolling PLWD or their care partners from 2011 to 2021. We abstracted characteristics of primary and secondary outcome measures, including pragmatic characteristics using an adapted Psychometric and Pragmatic Evidence Rating Scale and ACP outcome domains using the standardized ACP Outcome Framework (i.e., process, action, healthcare, or quality of care). RESULTS We included 21 ACP RCTs. Trials included 103 outcome measures (39 primary and 64 secondary), of which 11% measured process, 14% measured action, 49% measured healthcare, and 26% measured quality of care. Twenty-four (23%) outcome measures were highly pragmatic, the majority of which (67%) reflected healthcare outcome measures. Sixty-one (59%) outcomes were assessed as highly relevant to PLWD or their care partners. Only 20% (n = 21) of outcome measures were embedded into clinical practice. Most (62%) RCTs were conducted in nursing homes, and 33% were focused PLWD with advanced stage disease. CONCLUSIONS In RCTs testing ACP interventions to support PLWD, only 23% of outcome measures were highly pragmatic, and most of these measured healthcare utilizations. Outcome assessments were rarely integrated into the EHR during routine clinical care. New outcome measures that address the lived experience of PLWD and their care partners plus have high pragmatic characteristics are needed for embedded pragmatic clinical trials.
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Affiliation(s)
- Jennifer L Gabbard
- School of Medicine, Section of Gerontology and Geriatrics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Joan G Carpenter
- School of Nursing, Department of Organizational and Adult Health, University of Maryland, College Park, Maryland, USA
| | | | - Kimberly Mournighan
- Division of Geriatric Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Isabella Cornea
- School of Medicine, Section of Gerontology and Geriatrics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Mark McKone
- School of Medicine, Section of Gerontology and Geriatrics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
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Gleason KT, Powell DS, Wec A, Zou X, Gamper MJ, Peereboom D, Wolff JL. Patient portal interventions: a scoping review of functionality, automation used, and therapeutic elements of patient portal interventions. JAMIA Open 2023; 6:ooad077. [PMID: 37663406 PMCID: PMC10469545 DOI: 10.1093/jamiaopen/ooad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023] Open
Abstract
Objectives We sought to understand the objectives, targeted populations, therapeutic elements, and delivery characteristics of patient portal interventions. Materials and Methods Following Arksey and O-Malley's methodological framework, we conducted a scoping review of manuscripts published through June 2022 by hand and systematically searching PubMed, PSYCHInfo, Embase, and Web of Science. The search yielded 5403 manuscripts; 248 were selected for full-text review; 81 met the eligibility criteria for examining outcomes of a patient portal intervention. Results The 81 articles described: trials involving comparison groups (n = 37; 45.7%), quality improvement initiatives (n = 15; 18.5%), pilot studies (n = 7; 8.6%), and single-arm studies (n = 22; 27.2%). Studies were conducted in primary care (n = 33, 40.7%), specialty outpatient (n = 24, 29.6%), or inpatient settings (n = 4, 4.9%)-or they were deployed system wide (n = 9, 11.1%). Interventions targeted specific health conditions (n = 35, 43.2%), promoted preventive services (n = 19, 23.5%), or addressed communication (n = 19, 23.4%); few specifically sought to improve the patient experience (n = 3, 3.7%). About half of the studies (n = 40, 49.4%) relied on human involvement, and about half involved personalized (vs exclusively standardized) elements (n = 42, 51.8%). Interventions commonly collected patient-reported information (n = 36, 44.4%), provided education (n = 35, 43.2%), or deployed preventive service reminders (n = 14, 17.3%). Discussion This scoping review finds that most patient portal interventions have delivered education or facilitated collection of patient-reported information. Few interventions have involved pragmatic designs or been deployed system wide. Conclusion The patient portal is an important tool in real-world efforts to more effectively support patients, but interventions to date rely largely on evidence from consented participants rather than pragmatically implemented systems-level initiatives.
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Affiliation(s)
- Kelly T Gleason
- Johns Hopkins University School of Nursing, Baltimore, MD 21225, United States
| | - Danielle S Powell
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Aleksandra Wec
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Xingyuan Zou
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Mary Jo Gamper
- Johns Hopkins University School of Nursing, Baltimore, MD 21225, United States
| | - Danielle Peereboom
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
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Yoo JW, Reed PS, Shen JJ, Carson J, Kang M, Reeves J, Kim Y, Choe I, Kim P, Kim L, Kang HT, Tabrizi M. Impact of Advance Care Planning on the Hospitalization-Associated Utilization and Cost of Patients with Alzheimer's Disease-Related Disorders Receiving Primary Care via Telehealth in a Provider Shortage Area: A Quantitative Pre-Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6157. [PMID: 37372743 PMCID: PMC10298291 DOI: 10.3390/ijerph20126157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/23/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
Telehealth has been adopted as an alternative to in-person primary care visits. With multiple participants able to join remotely, telehealth can facilitate the discussion and documentation of advance care planning (ACP) for those with Alzheimer's disease-related disorders (ADRDs). We measured hospitalization-associated utilization outcomes, instances of hospitalization and 90-day re-hospitalizations from payors' administrative databases and verified the data via electronic health records. We estimated the hospitalization-associated costs using the Nevada State Inpatient Dataset and compared the estimated costs between ADRD patients with and without ACP documentation in the year 2021. Compared to the ADRD patients without ACP documentation, those with ACP documentation were less likely to be hospitalized (mean: 0.74; standard deviation: 0.31; p < 0.01) and were less likely to be readmitted within 90 days of discharge (mean: 0.16; standard deviation: 0.06; p < 0.01). The hospitalization-associated cost estimate for ADRD patients with ACP documentation (mean: USD 149,722; standard deviation: USD 80,850) was less than that of the patients without ACP documentation (mean: USD 200,148; standard deviation: USD 82,061; p < 0.01). Further geriatrics workforce training is called for to enhance ACP competencies for ADRD patients, especially in areas with provider shortages where telehealth plays a comparatively more important role.
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Affiliation(s)
- Ji Won Yoo
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89154, USA
| | - Peter S. Reed
- Sanford Center for Aging, Reno School of Medicine, University of Nevada, Reno, NV 89557, USA
- School of Public Health, University of Nevada, Reno, NV 89557, USA
| | - Jay J. Shen
- School of Public Health, University of Nevada, Las Vegas, NV 89119, USA (Y.K.)
| | - Jennifer Carson
- Sanford Center for Aging, Reno School of Medicine, University of Nevada, Reno, NV 89557, USA
- School of Public Health, University of Nevada, Reno, NV 89557, USA
| | - Mingon Kang
- Department of Computer Science, Howard Hughes College of Engineering, University of Nevada, Las Vegas, NV 89154, USA
| | | | - Yonsu Kim
- School of Public Health, University of Nevada, Las Vegas, NV 89119, USA (Y.K.)
| | - Ian Choe
- Telehealth Divison, Optum Care Network of Nevada, Las Vegas, NV 89128, USA;
| | - Pearl Kim
- School of Public Health, University of Nevada, Las Vegas, NV 89119, USA (Y.K.)
| | - Laurie Kim
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV 89154, USA
| | - Hee-Taik Kang
- Department of Family Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Maryam Tabrizi
- Department of Clinical Sciences, School of Dental Medicine, University of Nevada, Las Vegas, NV 89154, USA
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