Patient and Provider Perspectives About the Use of Patient-Generated Health Data During Pregnancy: Qualitative Exploratory Study.

BACKGROUND: There is increasing interest in using patient-generated health data (PGHD) to improve patient-centered care during pregnancy. However, little research has examined the perspectives of patients and providers as they report, collect, and use PGHD to inform obstetric care. OBJECTIVE: This study aims to explore the perspectives of patients and providers about the use of PGHD during pregnancy, including the benefits and challenges of reporting, collecting, and using these data, as well as considerations for expanding the use of PGHD to improve obstetric care. METHODS: We conducted one-on-one interviews with 30 pregnant or postpartum patients and 14 health care providers from 2 obstetrics clinics associated with an academic medical center. Semistructured interview guides included questions for patients about their experience and preferences for sharing PGHD and questions for providers about current processes for collecting PGHD, opportunities to improve or expand the collection of PGHD, and challenges faced when collecting and using this information. Interviews were conducted by phone or videoconference and were audio recorded, transcribed verbatim, and deidentified. Interview transcripts were analyzed deductively and inductively to characterize and explore themes in the data. RESULTS: Patients and providers described how PGHD, including physiologic measurements and experience of symptoms, were currently collected during and between in-person clinic visits for obstetric care. Both patients and providers reported positive perceptions about the collection and use of PGHD during pregnancy. Reported benefits of collecting PGHD included the potential to use data to directly inform patient care (eg, identify issues and adjust medication) and to encourage ongoing patient involvement in their care (eg, increase patient attention to their health). Patients and providers had suggestions for expanding the collection and use of PGHD during pregnancy, and providers also shared considerations about strategies that could be used to expand PGHD collection and use. These strategies included considering the roles of both patients and providers in reporting and interpreting PGHD. Providers also noted the need to consider the unintended consequences of using PGHD that should be anticipated and addressed. CONCLUSIONS: Acknowledging the challenges, suggestions, and considerations voiced by patients and providers can inform the development and implementation of strategies to effectively collect and use PGHD to support patient-centered care during pregnancy.

Screening tools to address social determinants of health in the United States: A systematic review.

The Centers for Medicare & Medicaid Services have mandated that hospitals implement measures to screen social determinants of health (SDoH). We sought to report on available SDoH screening tools. PubMed, Scopus, Web of Science, as well as the grey literature were searched (1980 to November 2023). The included studies were US-based, written in English, and examined a screening tool to assess SDoH. Thirty studies were included in the analytic cohort. The number of questions in any given SDoH assessment tool varied considerably and ranged from 5 to 50 (mean: 16.6). A total of 19 SDoH domains were examined. Housing (n = 23, 92%) and safety/violence (n = 21, 84%) were the domains assessed most frequently. Food/nutrition (n = 17, 68%), income/financial (n = 16, 64%), transportation (n = 15, 60%), family/social support (n = 14, 56%), utilities (n = 13, 52%), and education/literacy (n = 13, 52%) were also commonly included domains in most screening tools. Eighteen studies proposed specific interventions to address SDoH. SDoH screening tools are critical to identify various social needs and vulnerabilities to help develop interventions to address patient needs. Moreover, there is marked heterogeneity of SDoH screening tools, as well as the significant variability in the SDoH domains assessed by currently available screening tools.

Association Between Neighborhood Opportunity, Allostatic Load, and All-Cause Mortality in Patients With Breast Cancer.

PURPOSE: Adverse neighborhood contextual factors may affect breast cancer outcomes through environmental, psychosocial, and biological pathways. The objective of this study is to examine the relationship between allostatic load (AL), neighborhood opportunity, and all-cause mortality among patients with breast cancer. METHODS: Women age 18 years and older with newly diagnosed stage I-III breast cancer who received surgical treatment between January 1, 2012, and December 31, 2020, at a National Cancer Institute Comprehensive Cancer Center were identified. Neighborhood opportunity was operationalized using the 2014-2018 Ohio Opportunity Index (OOI), a composite measure derived from neighborhood level transportation, education, employment, health, housing, crime, and environment. Logistic and Cox regression models tested associations between the OOI, AL, and all-cause mortality. RESULTS: The study cohort included 4,089 patients. Residence in neighborhoods with low OOI was associated with high AL (adjusted odds ratio, 1.21 [95% CI, 1.05 to 1.40]). On adjusted analysis, low OOI was associated with greater risk of all-cause mortality (adjusted hazard ratio [aHR], 1.45 [95% CI, 1.11 to 1.89]). Relative to the highest (99th percentile) level of opportunity, risk of all-cause mortality steeply increased up to the 70th percentile, at which point the rate of increase plateaued. There was no interaction between the composite OOI and AL on all-cause mortality (P = .12). However, there was a higher mortality risk among patients with high AL residing in lower-opportunity environments (aHR, 1.96), but not in higher-opportunity environments (aHR, 1.02; P interaction = .02). CONCLUSION: Lower neighborhood opportunity was associated with higher AL and greater risk of all-cause mortality among patients with breast cancer. Additionally, environmental factors and AL interacted to influence all-cause mortality. Future studies should focus on interventions at the neighborhood and individual level to address socioeconomically based disparities in breast cancer.

Developing a multimodal maternal infant perinatal outpatient delivery system: the MOMI PODS program.

Progress in maternal child health has been hampered by poor rates of outpatient follow up for postpartum individuals. Primary care after delivery can effectively detect and treat several pregnancy-related complications and comorbidities, but postpartum linkage to primary care remains low. In this manuscript, we share the experience of implementing a novel mother-infant dyad program, the Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS), to improve primary care linkage and community resource access postpartum via integration into pediatric care structures. With a focus on providing care for people who are publicly insured, we designed a program to mitigate maternal morbidity risk factors in postpartum individuals with chronic disease or pregnancy complications. We discuss the systematic process of designing, executing, and evaluating a collaborative clinical program with involvement of internal medicine/pediatric, family medicine, and obstetric clinicians via establishing stakeholders, identifying best practices, drawing from the evidence base, designing training and promotional materials, training partners and providers, and evaluating clinic enrollment. We share the challenges encountered such as in achieving sufficient provider capacity, consistent provision of care, scheduling, and data tracking, as well as mitigation strategies to overcome these barriers. Overall, MOMI PODS is an innovative approach that integrates outpatient postpartum care into traditional pediatric structures to increase access, showing significant promise to improve healthcare utilization and promote postpartum health.

An Evidence-Based Framework for Creating Inclusive and Personalized mHealth Solutions-Designing a Solution for Medicaid-Eligible Pregnant Individuals With Uncontrolled Type 2 Diabetes.

Mobile health (mHealth) apps can be an evidence-based approach to improve health behavior and outcomes. Prior literature has highlighted the need for more research on mHealth personalization, including in diabetes and pregnancy. Critical gaps exist on the impact of personalization of mHealth apps on patient engagement, and in turn, health behaviors and outcomes. Evidence regarding how personalization, engagement, and health outcomes could be aligned when designing mHealth for underserved populations is much needed, given the historical oversights with mHealth design in these populations. This viewpoint is motivated by our experience from designing a personalized mHealth solution focused on Medicaid-enrolled pregnant individuals with uncontrolled type 2 diabetes, many of whom also experience a high burden of social needs. We describe fundamental components of designing mHealth solutions that are both inclusive and personalized, forming the basis of an evidence-based framework for future mHealth design in other disease states with similar contexts.

Establishing a clinical informatics umbilical cord: lessons learned in launching infrastructure to support dyadic mother/infant primary care.

The Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS) was developed to facilitate the pregnancy to postpartum primary care transition, particularly for individuals at risk for severe maternal morbidity, via a unique multidisciplinary model of mother/infant dyadic primary care. Specialized clinical informatics platforms are critical to ensuring the feasibility and scalability of MOMI PODS and a smooth perinatal transition into longitudinal postpartum primary care. In this manuscript, we describe the MOMI PODS transition and management clinical informatics platforms developed to facilitate MOMI PODS referrals, scheduling, evidence-based multidisciplinary care, and program evaluation. We discuss opportunities and lessons learned associated with our applied methods, as advances in clinical informatics have considerable potential to enhance the quality and evaluation of innovative maternal health programs like MOMI PODS.

Patient and provider perspectives on the use of patient portals during pregnancy and the postpartum period.

INTRODUCTION: Interest in the use of patient portals to support prenatal and postpartum care is growing. This study was conducted to understand patient and provider perspectives about the impact of portal use during pregnancy and the postpartum period. METHODS: Interviews were conducted with 30 pregnant or postpartum patients and 15 obstetric care providers at an academic medical center that offers its patients access to an outpatient portal. Interview transcripts were analyzed deductively and inductively to categorize findings and identify emergent themes. RESULTS: Patients and providers described how use of a patient portal during pregnancy and postpartum impacted communication (by supporting convenient communication and access to information), care processes (by aiding appointment attendance and helping with medication management), and care experience (by reducing anxiety and promoting patient involvement). Interviewees provided suggestions to improve patient portal use in obstetric care including using portals to increase access to educational materials and supportive resources, to collect patient-generated data, and to increase patient involvement in postpartum care. DISCUSSION: Patient portals have particular value for patients' use during pregnancy and the postpartum period due to the frequency of healthcare visits and the heightened attention to one's health during this time. There are opportunities to tailor portal content and functions to patients' needs to improve communication, care processes, and care experiences for this patient population. Further improving the functionality of patient portals for patients' use during pregnancy and the postpartum period has the potential to positively impact patient experiences and health outcomes.

Multicomponent provider-patient intervention to improve glycaemic control in Medicaid-insured pregnant individuals with type 2 diabetes: clinical trial protocol for the ACHIEVE study.

INTRODUCTION: Type 2 diabetes (T2D) is one of the most frequent comorbid medical conditions in pregnancy. Glycaemic control decreases the risk of adverse pregnancy outcomes for the pregnant individual and infant. Achieving glycaemic control can be challenging for Medicaid-insured pregnant individuals who experience a high burden of unmet social needs. Multifaceted provider-patient-based approaches are needed to improve glycaemic control in this high-risk pregnant population. Mobile health (mHealth) applications (app), provider dashboards, continuous glucose monitoring (CGM) and addressing social needs have been independently associated with improved glycaemic control in non-pregnant individuals living with diabetes. The combined effect of these interventions on glycaemic control among pregnant individuals with T2D remains to be evaluated. METHODS AND ANALYSIS: In a two-arm randomised controlled trial, we will examine the combined effects of a multicomponent provider-patient intervention, including a patient mHealth app, provider dashboard, CGM, a community health worker to address non-medical health-related social needs and team-based care versus the current standard of diabetes and prenatal care. We will recruit 124 Medicaid-insured pregnant individuals living with T2D, who are ≤20 weeks of gestation with poor glycaemic control measured as a haemoglobin A1c ≥ 6.5% assessed within 12 weeks of trial randomisation or within 12 weeks of enrolling in prenatal care from an integrated diabetes and prenatal care programme at a tertiary care academic health system located in the Midwestern USA. We will measure how many individuals achieve the primary outcome of glycaemic control measured as an A1c<6.5% by the time of delivery, and secondarily, adverse pregnancy outcomes; patient-reported outcomes (eg, health and technology engagement, literacy and comprehension; provider-patient communication; diabetes self-efficacy; distress, knowledge and beliefs; social needs referrals and utilisation; medication adherence) and CGM measures of glycaemic control (in the intervention group). ETHICS AND DISSEMINATION: The Institutional Review Board at The Ohio State University approved this study (IRB: 2022H0399; date: 3 June 2023). We plan to submit manuscripts describing the user-designed methods and will submit the results of the trial for publication in peer-reviewed journals and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER: NCT05662462.

Disparities in Continuous Glucose Monitoring Use Among Women of Reproductive Age with Type 1 Diabetes in the T1D Exchange.

We identified characteristics associated with continuous glucose monitoring (CGM) use in women of reproductive age with type 1 diabetes (T1D) in the T1D Exchange clinic registry from 2015 to 2018. Among 6643 assessed women, the frequency of CGM increased from 2015 to 2018 (20.6% vs. 30.0%; adjusted odds ratios [aOR]: 1.72; confidence interval [95% CI]: 1.51-1.95) and was more likely with recent pregnancy (45.3% vs. 25.8%; aOR: 1.63; 95% CI: 1.23-2.16). Non-Hispanic Black and Hispanic race and ethnicity, younger age, lower educational attainment, lower income, and Medicaid insurance were associated with lower odds of CGM. The use of CGM was associated with lower odds of diabetic ketoacidosis and lower hemoglobin A1c without any difference in the odds of symptomatic severe hypoglycemia. In conclusion, although CGM use was associated with better glycemic control, the majority of reproductive-age women still did not use it. Those who did not use CGM were more likely to be those at greatest risk of adverse pregnancy outcomes.

Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes.

Importance: Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening. Objective: To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum. Design, Setting, and Participants: This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022. Main Outcomes and Measures: Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively. Results: A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum. Conclusions and Relevance: In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

Association of community walkability and glycemic control among pregnant individuals with pregestational diabetes mellitus.

BACKGROUND: Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined. OBJECTIVE: This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes. STUDY DESIGN: This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type. RESULTS: Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability. CONCLUSION: Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.

Developing and testing an integrated patient mHealth and provider dashboard application system for type 2 diabetes management among Medicaid-enrolled pregnant individuals based on a user-centered approach: Mixed-methods study.

Background: A tailored and integrated technology solution (patient mHealth application and provider dashboard) can provide a 360° view of Medicaid-enrolled patients with type 2 diabetes (T2D) during pregnancy that could improve health outcomes and address health inequities. Objectives: To develop a set of user specifications for the mHealth and dashboard applications, develop prototypes based on user needs, and collect initial impressions of the prototypes to subsequently develop refined tools that are ready for deployment. Methods: Study activities followed a double-diamond framework with a participatory design mindset. Activities were divided into two phases focused on a qualitative inquiry about participant needs and values (phase 1) and design, development, and usability testing of low and high-fidelity prototypes (phase 2). Results: We identified themes that exemplified pregnancy experience among Medicaid-enrolled individuals with T2D. Patients (n = 7) and providers (n = 7) expressed a core set of expectations for the mHealth and dashboard applications. Participants provided feedback to improve the mHealth and dashboard. For both applications, participants reported scores for the NASA Task load Survey (TLX) that were in the 20th percentile of national TLX scores. Conclusions: Digital health tools have the ability to transform health care among Medicaid-enrolled patients with T2D during pregnancy, with the goal of managing their blood glucose levels, which is a precursor to experiencing a successful pregnancy and birth. Distilling patient and provider needs and preferences-then using them, along with prior studies and theory, to develop applications-holds great potential in tackling complicated health care issues.

Attitudes towards and sociodemographic determinants of genetic test usage in the USA; data from the Health Information National Trend Survey, 2020.

The purpose of this study was to examine the trends in who obtains genetic tests, and opinions about how genes affect health. Cross-sectional survey data from Health Information National Trends Survey (HINTS) 5, Cycle 4 was used. This data was collected from adults 18 years of age or older who completed mailed surveys sent by the National Cancer Institute between January and April 2020. The sample consisted of 2,947 respondents who answered the question 'Have you ever had a genetic test'? 727 had a test and 2,220 did not have a test. The measures used included survey questions that asked whether respondents obtained certain kinds of genetic tests, who they shared test results with, whether they believed genes affect health status, and their demographic and cancer status information. Multivariate logistic regression models were developed to assess which demographic variables were associated with having different kinds of genetic tests, and whether those who had genetic tests had different opinions about genetic testing and the influence of genes on health. We found that female respondents [OR: 1.9; CI: (1.2-3.1)] had higher odds of having any genetic tests while Hispanic [OR: 0.5; CI: (0.2-1.0)] respondents had lower odds. Our findings indicate that there are demographic disparities in who received genetic tests, and that cancer risk alone does not explain the differences in prevalence of genetic testing.

Review of applied health informatics courses in a multidisciplinary biomedical informatics department.

Introduction: Applied health informatics infrastructure is a requirement for learning health systems and it is imperative that we train a workforce that can support this infrastructure. Our department offers courses in several interdisciplinary programs with topics ranging from bioinformatics to population health informatics. Due to changes in the field and our faculty members, we sought to assess our courses relevant to applied health informatics. Methods: In this paper, we discuss the three-phase evaluation of our program and include the survey we developed to identify the skills and knowledge base of our faculty. Results: We show how this assessment allowed us to identify gaps and develop strategies for program expansion. Conclusions: A focus on workforce development can help to guide and focus curricular review in an interdisciplinary graduate program.

Sequences of Events from the Electronic Medical Record and the Onset of Infection.

We present a novel model of time-series analysis to learn from electronic health record (EHR) data when infection occurred in the intensive care unit (ICU) by translating methods from proteomics and Bayesian statistics. Using 48,536 patients hospitalized in an ICU, we describe each hospital course as an 'alphabet' of 23 physician actions ('events') in temporal order. We analyze these as k-mers of length 3-12 events and apply a Bayesian model of (cumulative) relative risk (RR). The log2-transformed RR (median=0.248, mean=0.226) supported the conclusion that the events selected were individually associated with increased risk of infection. Selecting from all possible cutoffs of maximum gain (MG), MG>0.0244 predicts administration of antibiotics with PPV 82.0 %, NPV 44.4 %, and AUC 0.706. Our approach holds value for retrospective analysis of other clinical syndromes for which time-of-onset is critical to analysis but poorly marked in EHRs, including delirium and decompensation.

Effect of In-Person vs Video Training and Access to All Functions vs a Limited Subset of Functions on Portal Use Among Inpatients: A Randomized Clinical Trial.

Importance: Inpatient portals provide patients with clinical data and information about their care and have the potential to influence patient engagement and experience. Although significant resources have been devoted to implementing these portals, evaluation of their effects has been limited. Objective: To assess the effects of patient training and portal functionality on use of an inpatient portal and on patient satisfaction and involvement with care. Design, Setting, and Participants: This randomized clinical trial was conducted from December 15, 2016, to August 31, 2019, at 6 noncancer hospitals that were part of a single health care system. Patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay were eligible for participation. Data were analyzed from May 1, 2019, to March 15, 2021. Interventions: A 2 × 2 factorial intervention design was used to compare 2 levels of a training intervention (touch intervention, consisting of in-person training vs built-in video tutorial) and 2 levels of portal function availability (tech intervention) within an inpatient portal (all functions operational vs a limited subset of functions). Main Outcomes and Measures: The primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and patients' satisfaction and involvement with their care. Results: Of 2892 participants, 1641 were women (56.7%) with a median age of 47.0 (95% CI, 46.0-48.0) years. Most patients were White (2221 [76.8%]). The median Charlson Comorbidity Index was 1 (95% CI, 1-1) and the median length of stay was 6 (95% CI, 6-7) days. Notably, the in-person training intervention was found to significantly increase inpatient portal use (incidence rate ratio, 1.34 [95% CI, 1.25-1.44]) compared with the video tutorial. Patients who received in-person training had significantly higher odds of being comprehensive portal users than those who received the video tutorial (odds ratio, 20.75 [95% CI, 16.49-26.10]). Among patients who received the full-tech intervention, those who also received the in-person intervention used the portal more frequently (incidence rate ratio, 1.36 [95% CI, 1.25-1.48]) and more comprehensively (odds ratio, 22.52; [95% CI, 17.13-29.62]) than those who received the video tutorial. Patients who received in-person training had higher odds (OR, 2.01 [95% CI, 1.16-3.50]) of reporting being satisfied in the 6-month postdischarge survey. Similarly, patients who received the full-tech intervention had higher odds (OR, 2.06 [95%CI, 1.42-2.99]) of reporting being satisfied in the 6-month postdischarge survey. Conclusions and Relevance: Providing in-person training or robust portal functionality increased inpatient engagement with the portal during the hospital stay. The effects of the training intervention suggest that providing personalized training to support use of this health information technology can be a powerful approach to increase patient engagement via portals. Trial Registration: ClinicalTrials.gov Identifier: NCT02943109.

Construction of the Ohio Children's Opportunity Index.

Objective: To describe the development of an area-level measure of children's opportunity, the Ohio Children's Opportunity Index (OCOI). Data Sources/Study Setting: Secondary data were collected from US census based-American Community Survey (ACS), US Environmental Protection Agency, US Housing and Urban Development, Ohio Vital Statistics, US Department of Agriculture-Economic Research Service, Ohio State University Center for Urban and Regional Analysis, Ohio Incident Based Reporting System, IPUMS National Historical Geographic Information System, and Ohio Department of Medicaid. Data were aggregated to census tracts across two time periods. Study Design: OCOI domains were selected based on existing literature, which included family stability, infant health, children's health, access, education, housing, environment, and criminal justice domains. The composite index was developed using an equal weighting approach. Validation analyses were conducted between OCOI and health and race-related outcomes, and a national index. Principal Findings: Composite OCOI scores ranged from 0-100 with an average value of 74.82 (SD, 17.00). Census tracts in the major metropolitan cities across Ohio represented 76% of the total census tracts in the least advantaged OCOI septile. OCOI served as a significant predictor of health and race-related outcomes. Specifically, the average life expectancy at birth of children born in the most advantaged septile was approximately 9 years more than those born in least advantaged septile. Increases in OCOI were associated with decreases in proportion of Black (48 points lower in the most advantaged vs. least advantaged septile), p < 0.001) and Minority populations (54 points lower in most advantaged vs. least advantaged septile, p < 0.001). We found R-squared values > 0.50 between the OCOI and the national Child Opportunity Index scores. Temporally, OCOI decreased by 1% between the two study periods, explained mainly by decreases in the children health, accessibility and environmental domains. Conclusion: As the first opportunity index developed for children in Ohio, the OCOI is a valuable resource for policy reform, especially related to health disparities and health equity. Health care providers will be able to use it to obtain holistic views on their patients and implement interventions that can tackle barriers to childhood development using a more tailored approach.

Outpatient portal use among pregnant individuals: Cross-sectional, temporal, and cluster analysis of use.

Background: Outpatient portal technology can improve patient engagement. For pregnant individuals, the level of engagement could have important implications for maternal and infant outcomes. Objective: This study: (1) cross-sectionally and temporally characterized the outpatient portal use among pregnant individuals seen at our academic medical center; and (2) identified clusters of the outpatient portal user groups based on the cross-sectional and temporal patterns of use. Methods: We used outpatient portal server-side log files to execute a hierarchical clustering algorithm to group 7663 pregnant individuals based on proportions of outpatient portal function use. Post-hoc analyses were performed to further assess outpatient portal use on key encounter characteristics. Results: The most frequently used functions were MyRecord (access personal health information), Visits (manage appointments), Messaging (send/receive messages), and Billing (view bills, insurance information). Median outpatient portal function use plateaued by the third trimester. Four distinct clusters were identified among all pregnant individuals: "Schedulers," "Resulters," "Intense Digital Engagers," and "Average Users." Post-hoc analyses revealed that the use of the Visits function increased and the use of the MyRecord function decreased over time among clusters. Conclusions: Our identification of distinct cluster groups of outpatient portal users among pregnant individuals underscores the importance of avoiding the use of generalizations when describing how such patients might engage with patient-facing technologies such as an outpatient portal. These results can be used to improve user experience and training with outpatient portal functions and may educate maternal health providers on patient engagement with the outpatient portal.

Mothers' Perspectives on a Mother/Infant Dyad Postpartum Primary Care Program Following Gestational Diabetes Mellitus: A Qualitative Pilot Study.

PURPOSE: The purpose of this study is to characterize mothers' experiences within a mother/infant dyad postpartum primary care program (Dyad) following gestational diabetes mellitus (GDM) to inform improvements in the delivery of care. METHODS: A qualitative pilot study of women (n = 10) enrolled in a mother/infant Dyad program was conducted in a primary care practice at a large, urban academic medical center. Respondents were asked a series of open-ended questions about their experience with GDM, the Dyad program, and health behaviors. Interviews were audio-recorded, transcribed verbatim, and analyzed using ground theory with NVivo 12 Plus software. RESULTS: Three key themes emerged: (1) Dyad program experience, (2) implementation of health behavior changes, and (3) acknowledgment of future GDM and type 2 diabetes mellitus (T2DM) health risks. Respondents felt that the program conveniently served mother and infant health care needs in a single appointment. Respondents also valued support from primary care providers when implementing health behavior changes. The Dyad program provided an opportunity for respondents to understand their current and future risk for developing GDM and T2DM. CONCLUSIONS: Postpartum women enrolled in the Dyad program received highly personalized primary care services. The results of our study will help integrate patient-centered strategies into models for GDM care to maintain patient engagement in postpartum clinical services.

Association Between Social Vulnerability and Achieving Glycemic Control Among Pregnant Individuals With Pregestational Diabetes.

OBJECTIVE: To evaluate the association between community-level social vulnerability and achieving glycemic control (defined as hemoglobin A1c [Hb A1c] less than 6.0% or less than 6.5%) among individuals with pregestational diabetes. METHODS: We conducted a retrospective cohort of individuals with pregestational diabetes with singleton gestations from 2012 to 2016 at a tertiary care center. Addresses were geocoded using ArcGIS and then linked at the census tract to the Centers for Disease Control and Prevention's 2018 SVI (Social Vulnerability Index), which incorporates 15 Census variables to produce a composite score and four scores across thematic domains (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation). Scores range from 0 to 1, with higher values indicating greater community-level social vulnerability. The primary outcome was Hb A1c less than 6.0%, and, secondarily, Hb A1c less than 6.5%, in the second or third trimesters. Multivariable Poisson regression with robust error variance was used to evaluate the association between SVI score as a continuous measure and target Hb A1c. RESULTS: Among 418 assessed pregnant individuals (33.0% type 1; 67.0% type 2 diabetes), 41.4% (173/418) achieved Hb A1c less than 6.0%, and 56.7% (237/418) Hb A1c less than 6.5% at a mean gestational age of 29.5 weeks (SD 5.78). Pregnant individuals with a higher SVI score were less likely to achieve Hb A1c less than 6.0% compared with those with a lower SVI score. For each 0.1-unit increase in SVI score, the risk of achieving Hb A1c less than 6.0% decreased by nearly 50% (adjusted risk ratio [aRR] 0.53; 95% CI 0.36-0.77), and by more than 30% for Hb A1c less than 6.5% (adjusted odds ratio 0.67; 95% CI 0.51-0.88). With regard to specific SVI domains, those who scored higher on socioeconomic status (aRR 0.50; 95% CI 0.35-0.71) as well as on household composition and disability (aRR 0.55; 95% CI 0.38-0.79) were less likely to achieve Hb A1c less than 6.0%. CONCLUSION: Pregnant individuals with pregestational diabetes living in an area with higher social vulnerability were less likely to achieve glycemic control, as measured by HgbA1c levels. Interventions are needed to assess whether addressing social determinants of health can improve glycemic control in pregnancy.