Secure Messaging for Diabetes Management: Content Analysis.

BACKGROUND: Secure messaging use is associated with improved diabetes-related outcomes. However, it is less clear how secure messaging supports diabetes management. OBJECTIVE: We examined secure message topics between patients and clinical team members in a national sample of veterans with type 2 diabetes to understand use of secure messaging for diabetes management and potential associations with glycemic control. METHODS: We surveyed and analyzed the content of secure messages between 448 US Veterans Health Administration patients with type 2 diabetes and their clinical teams. We also explored the relationship between secure messaging content and glycemic control. RESULTS: Explicit diabetes-related content was the most frequent topic (72.1% of participants), followed by blood pressure (31.7% of participants). Among diabetes-related conversations, 90.7% of patients discussed medication renewals or refills. More patients with good glycemic control engaged in 1 or more threads about blood pressure compared to those with poor control (37.5% vs 27.2%, P=.02). More patients with good glycemic control engaged in 1 more threads intended to share information with their clinical team about an aspect of their diabetes management compared to those with poor control (23.7% vs 12.4%, P=.009). CONCLUSIONS: There were few differences in secure messaging topics between patients in good versus poor glycemic control. Those in good control were more likely to engage in informational messages to their team and send messages related to blood pressure. It may be that the specific topic content of the secure messages may not be that important for glycemic control. Simply making it easier for patients to communicate with their clinical teams may be the driving influence between associations previously reported in the literature between secure messaging and positive clinical outcomes in diabetes.

Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis.

BACKGROUND: Rural patients with diabetes have difficulty accessing care and are at higher risk for poor diabetes management. Sustained use of patient portal features such as secure messaging (SM) can provide accessible support for diabetes self-management. OBJECTIVE: This study explored whether rural patients' self-management and glycemic control was associated with the use of SM. METHODS: This secondary, cross-sectional, mixed methods analysis of 448 veterans with diabetes used stratified random sampling to recruit a diverse sample from the United States (rural vs urban and good vs poor glycemic control). Administrative, clinical, survey, and interview data were used to determine patients' rurality, use of SM, diabetes self-management behaviors, and glycemic control. Moderated mediation analyses assessed these relationships. RESULTS: The sample was 51% (n=229) rural and 49% (n=219) urban. Mean participant age was 66.4 years (SD 7.7 years). More frequent SM use was associated with better diabetes self-management (P=.007), which was associated with better glycemic control (P<.001). Among rural patients, SM use was indirectly associated with better glycemic control through improved diabetes self-management (95% CI 0.004-0.927). These effects were not observed among urban veterans with diabetes (95% CI -1.039 to 0.056). Rural patients were significantly more likely than urban patients to have diabetes-related content in their secure messages (P=.01). CONCLUSIONS: More frequent SM use is associated with engaging in diabetes self-management, which, in turn, is associated with better diabetes control. Among rural patients with diabetes, SM use is indirectly associated with better diabetes control. Frequent patient-team communication through SM about diabetes-related content may help rural patients with diabetes self-management, resulting in better glycemic control.

Patient portal engagement and diabetes management among new portal users in the Veterans Health Administration.

OBJECTIVE: The study sought to investigate whether consistent use of the Veterans Health Administration's My HealtheVet (MHV) online patient portal is associated with improvement in diabetes-related physiological measures among new portal users. MATERIALS AND METHODS: We conducted a retrospective cohort study of new portal users with type 2 diabetes that registered for MHV between 2012 and 2016. We used random-effect linear regression models to examine associations between months of portal use in a year (consistency) and annual means of the physiological measures (hemoglobin A1c [HbA1c], low-density lipoproteins [LDLs], and blood pressure [BP]) in the first 3 years of portal use. RESULTS: For patients with uncontrolled HbA1c, LDL, or BP at baseline, more months of portal use in a year was associated with greater improvement. Compared with 1 month of use, using the portal 12 months in a year was associated with annual declines in HbA1c of -0.41% (95% confidence interval [CI], -0.46% to -0.36%) and in LDL of -6.25 (95% CI, -7.15 to -5.36) mg/dL. Twelve months of portal use was associated with minimal improvements in BP: systolic BP of -1.01 (95% CI, -1.33 to -0.68) mm Hg and diastolic BP of -0.67 (95% CI, -0.85 to -0.49) mm Hg. All associations were smaller or not present for patients in control of these measures at baseline. CONCLUSIONS: We found consistent use of the patient portal among new portal users to be associated with modest improvements in mean HbA1c and LDL for patients at increased risk at baseline. For patients with type 2 diabetes, self-management supported by online patient portals may help control HbA1c, LDL, and BP.

Study design and rationale for a randomized controlled trial to assess effectiveness of stochastic vibrotactile mattress stimulation versus standard non-oscillating crib mattress for treating hospitalized opioid-exposed newborns.

The incidence of Neonatal Abstinence Syndrome (NAS) continues to rise and there remains a critical need to develop non-pharmacological interventions for managing opioid withdrawal in newborns. Objective physiologic markers of opioid withdrawal in the newborn remain elusive. Optimal treatment strategies for improving short-term clinical outcomes and promoting healthy neurobehavioral development have yet to be defined. This dual-site randomized controlled trial (NCT02801331) is designed to evaluate the therapeutic efficacy of stochastic vibrotactile stimulation (SVS) for reducing withdrawal symptoms, pharmacological treatment, and length of hospitalization, and for improving developmental outcomes in opioid-exposed neonates. Hospitalized newborns (n = 230) receiving standard clinical care for prenatal opioid exposure will be randomly assigned within 48-hours of birth to a crib with either: 1) Intervention (SVS) mattress: specially-constructed SVS crib mattress that delivers gentle vibrations (30-60 Hz, ~12 µm RMS surface displacement) at 3-hr intervals; or 2) Control mattress (treatment as usual; TAU): non-oscillating hospital-crib mattress. Infants will be studied throughout their hospitalization and post discharge to 14-months of age. The study will compare clinical measures (i.e., withdrawal scores, cumulative dose and duration of medications, velocity of weight gain) and characteristic progression of physiologic activity (i.e., limb movement, cardio-respiratory, temperature, blood-oxygenation) throughout hospitalization between opioid-exposed infants who receive SVS and those who receive TAU. Developmental outcomes (i.e., physical, social, emotional and cognitive) within the first year of life will be evaluated between the two study groups. Findings from this randomized controlled trial will determine whether SVS reduces in-hospital severity of NAS, improves physiologic function, and promotes healthy development.

The Promise of Patient Portals for Individuals Living With Chronic Illness: Qualitative Study Identifying Pathways of Patient Engagement.

BACKGROUND: Patients play a critical role in managing their health, especially in the context of chronic conditions like diabetes. Electronic patient portals have been identified as a potential means to improve patient engagement; that is, patients' involvement in their care. However, little is known about the pathways through which portals may help patients engage in their care. OBJECTIVE: Our objective is to understand how an electronic patient portal facilitates patient engagement among individuals with diabetes. METHODS: This qualitative study employed semistructured telephone interviews of 40 patients living with diabetes since at least 2011, who had experienced uncontrolled diabetes, and had used secure messaging through a portal at least 4 times over 18 months. The interviews were recorded, transcribed, coded, and analyzed using primarily an inductive approach to identify how patients living with diabetes use an online health portal to support diabetes self-management. RESULTS: Overall, patients who used the portal reported feeling engaged in their health care. We identified four pathways by which the portal facilitates patient engagement and some challenges. The portal provides a platform that patients use to (1) better understand their health by asking questions about new symptoms, notes, or labs, (2) prepare for medical appointments by reviewing labs and notes, (3) coordinate care between VA (Veterans Affairs) and non-VA health care teams, and (4) reach out to providers to request help between visits. Several patients reported that the portal helped improve the patient-provider relationship; however, aspects of the portal design may hinder engagement for others. Patients reported challenges with both secure messaging and access to medical records that had negative impacts on their engagement. Benefits for patient engagement were described by many types of portal users with varying degrees of diabetes control. CONCLUSIONS: Patient portals support engagement by facilitating patient access to their health information and by facilitating patient-provider communication. Portals can help a wide range of users engage with their care.

Secure Messaging, Diabetes Self-management, and the Importance of Patient Autonomy: a Mixed Methods Study.

BACKGROUND: Diabetes is a complex, chronic disease that requires patients' effective self-management between clinical visits; this in turn relies on patient self-efficacy. The support of patient autonomy from healthcare providers is associated with better self-management and greater diabetes self-efficacy. Effective provider-patient secure messaging (SM) through patient portals may improve disease self-management and self-efficacy. SM that supports patients' sense of autonomy may mediate this effect by providing patients ready access to their health information and better communication with their clinical teams. OBJECTIVE: We examined the association between healthcare team-initiated SM and diabetes self-management and self-efficacy, and whether this association was mediated by patients' perceptions of autonomy support from their healthcare teams. DESIGN: We surveyed and analyzed content of messages sent to a sample of patients living with diabetes who use the SM feature on the VA's My HealtheVet patient portal. PARTICIPANTS: Four hundred forty-six veterans with type 2 diabetes who were sustained users of SM. MAIN MEASURES: Proactive (healthcare team-initiated) SM (0 or ≥ 1 messages); perceived autonomy support; diabetes self-management; diabetes self-efficacy. KEY RESULTS: Patients who received at least one proactive SM from their clinical team were significantly more likely to engage in better diabetes self-management and report a higher sense of diabetes self-efficacy. This relationship was mediated by the patient's perception of autonomy support. The majority of proactive SM discussed scheduling, referrals, or other administrative content. Patients' responses to team-initiated communication promoted patient engagement in diabetes self-management behaviors. CONCLUSIONS: Perceived autonomy support is important for diabetes self-management and self-efficacy. Proactive communication from clinical teams to patients can help to foster a patient's sense of autonomy and encourage better diabetes self-management and self-efficacy.