Electronic patient portals: evidence on health outcomes, satisfaction, efficiency, and attitudes: a systematic review.

BACKGROUND: Patient portals tied to provider electronic health record (EHR) systems are increasingly popular. PURPOSE: To systematically review the literature reporting the effect of patient portals on clinical care. DATA SOURCES: PubMed and Web of Science searches from 1 January 1990 to 24 January 2013. STUDY SELECTION: Hypothesis-testing or quantitative studies of patient portals tethered to a provider EHR that addressed patient outcomes, satisfaction, adherence, efficiency, utilization, attitudes, and patient characteristics, as well as qualitative studies of barriers or facilitators, were included. DATA EXTRACTION: Two reviewers independently extracted data and addressed discrepancies through consensus discussion. DATA SYNTHESIS: From 6508 titles, 14 randomized, controlled trials; 21 observational, hypothesis-testing studies; 5 quantitative, descriptive studies; and 6 qualitative studies were included. Evidence is mixed about the effect of portals on patient outcomes and satisfaction, although they may be more effective when used with case management. The effect of portals on utilization and efficiency is unclear, although patient race and ethnicity, education level or literacy, and degree of comorbid conditions may influence use. LIMITATION: Limited data for most outcomes and an absence of reporting on organizational and provider context and implementation processes. CONCLUSION: Evidence that patient portals improve health outcomes, cost, or utilization is insufficient. Patient attitudes are generally positive, but more widespread use may require efforts to overcome racial, ethnic, and literacy barriers. Portals represent a new technology with benefits that are still unclear. Better understanding requires studies that include details about context, implementation factors, and cost.

Diagnosing and managing common food allergies: a systematic review.

CONTEXT: There is heightened interest in food allergies but no clear consensus exists regarding the prevalence or most effective diagnostic and management approaches to food allergies. OBJECTIVE: To perform a systematic review of the available evidence on the prevalence, diagnosis, management, and prevention of food allergies. DATA SOURCES: Electronic searches of PubMed, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials. Searches were limited to English-language articles indexed between January 1988 and September 2009. STUDY SELECTION: Diagnostic tests were included if they had a prospective, defined study population, used food challenge as a criterion standard, and reported sufficient data to calculate sensitivity and specificity. Systematic reviews and randomized controlled trials (RCTs) for management and prevention outcomes were also used. For foods where anaphylaxis is common, cohort studies with a sample size of more than 100 participants were included. DATA EXTRACTION: Two investigators independently reviewed all titles and abstracts to identify potentially relevant articles and resolved discrepancies by repeated review and discussion. Quality of systematic reviews and meta-analyses was assessed using the AMSTAR criteria, the quality of diagnostic studies using the QUADAS criteria most relevant to food allergy, and the quality of RCTs using the Jadad criteria. DATA SYNTHESIS: A total of 12,378 citations were identified and 72 citations were included. Food allergy affects more than 1% to 2% but less than 10% of the population. It is unclear if the prevalence of food allergies is increasing. Summary receiver operating characteristic curves comparing skin prick tests (area under the curve [AUC], 0.87; 95% confidence interval [CI], 0.81-0.93) and serum food-specific IgE (AUC, 0.84; 95% CI, 0.78-0.91) to food challenge showed no statistical superiority for either test. Elimination diets are the mainstay of therapy but have been rarely studied. Immunotherapy is promising but data are insufficient to recommend use. In high-risk infants, hydrolyzed formulas may prevent cow's milk allergy but standardized definitions of high risk and hydrolyzed formula do not exist. CONCLUSION: The evidence for the prevalence and management of food allergy is greatly limited by a lack of uniformity for criteria for making a diagnosis.

Costs and benefits of health information technology: new trends from the literature.

To understand what is new in health information technology (IT), we updated a systematic review of health IT with studies published during 2004-2007. From 4,683 titles, 179 met inclusion criteria. We identified a proliferation of patient-focused applications although little formal evaluation in this area; more descriptions of commercial electronic health records (EHRs) and health IT systems designed to run independently from EHRs; and proportionately fewer relevant studies from the health IT leaders. Accelerating the adoption of health IT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding IT implementation.

Self-monitoring of blood glucose levels in patients with type 2 diabetes mellitus not taking insulin: a meta-analysis.

OBJECTIVE: To perform a meta-analysis of randomized controlled trials (RCTs) and systematic reviews evaluating the efficacy of self-monitoring of blood glucose (SMBG) levels among patients with diabetes mellitus (DM). STUDY DESIGN: Meta-analysis of RCTs among patients with DM not taking insulin comparing patients with SMBG versus those without SMBG and reporting results as change in glycosylated hemoglobin (A1C) values. METHODS: Prior systematic reviews and a PubMed search were used to identify studies. Data were extracted by trained physician reviewers working in duplicate. Trials were classified according to duration of the intervention, and random-effects meta-analysis was used to pool results. RESULTS: Three trials of SMBG of 3 months' duration were too heterogeneous to pool. Nine other trials were identified. Five trials of SMBG of 6 months' duration yielded a pooled effect estimate of a decrease in mean A1C values of -0.21% (95% confidence interval [CI], -0.38% to -0.04%). Four trials that reported outcomes of 1 year or longer yielded a pooled effect estimate of a decrease in mean A1C values of -0.16% (95% CI, -0.38% to 0.05%). Three trials reported hypoglycemic outcomes, which were increased in the patients using SMBG, although this mostly involved asymptomatic or mild episodes. CONCLUSIONS: At most, SMBG produces a statistically significant but clinically modest effect in controlling blood glucose levels in patients with DM not taking insulin. It is of questionable value in helping meet target values of glucose control.

Consumer usage patterns of nonprescription histamine2-receptor antagonists.

OBJECTIVE: Prescription to over-the-counter (OTC) drug switches are increasingly common. Yet little is known about how the public uses these reclassified products. Histamine2-receptor antagonists (H2RAs) are popular examples, although they may be supplanted by OTC proton pump inhibitors (PPIs). We examined the extent to which consumers substitute OTC H2RAs for physician care and/or engage in off-label use of these medications. METHODS: Self-administered anonymous survey of 1,116 adult OTC H2RA consumers in a random sample of 20 Los Angeles pharmacies from a major retail chain. Off-label use was defined by FDA warning label (e.g., bloody stools, dysphagia). Substitution was defined by intent to use H2RA instead of going to a physician. RESULTS: Forty-six percent engaged in off-label use of OTC H2RAs. Off-label use was independently associated with lower income, substitution for physician care, prior gastrointestinal disease, and past prescription H2RA use. Thirty-four percent substituted OTC H2RA use for physician care, and 54% of these met the criteria for off-label use. Substitution was associated with lack of health insurance, lack of time to see a physician, the belief that OTC H2RA was cheaper than clinic visits, and nonwhite race. CONCLUSION: Almost one-half of adult consumers reported using OTC H2RAs in a manner inconsistent with FDA labeling, and this off-label use was associated with substitution for physician care. Traditionally vulnerable populations were more prone to off-label use and to substituting H2RAs for physician care. Further studies are needed to assess patient outcomes, identify remedies, and explore implications for the reclassification of PPIs.