Optimizing Telehealth Services: A Mixed-Methods Needs Assessment Conducted Among Community Health Center Patients.

BACKGROUND: The COVID-19 pandemic increased telehealth services in federally funded community health centers (CHCs). Yet little is known about common determinants of use among CHC patients. OBJECTIVE: We examined the use of telehealth among patient participants at 1 large CHC network providing care to underserved populations at urban and suburban sites in the Midwest. METHODS: We conducted a mixed-methods study utilizing a sequential explanatory design. Participants were English and/or Spanish-speaking adults who attended ≥1 visits for themselves or their child over a 12-month period at any practice location. Research staff conducted a structured phone survey of eligible adults. The results subsequently facilitated purposive sampling of telehealth "users" and "nonusers" for qualitative phone interviews. RESULTS: The survey participants included 500 adults. Most had access to the resources needed to utilize telehealth, including a smartphone (90.4%) and home internet (83.0%). About half (50.8%) "rarely or never" had problems with internet speed, reliability, or quality. Most (81.1%) were aware of the patient portal and 59.8% had utilized video visits. Participants who were Spanish-speaking and with limited English proficiency faced some of the greatest barriers. Qualitative interview participants included 12 users and 12 nonusers of telehealth. Users found telehealth convenient and efficient, while nonusers lacked awareness about how telehealth services could be beneficial or needed assistance to sign up, join, or use telehealth. CONCLUSIONS: Most participants had the resources and awareness necessary to use telehealth services. Those who use them appreciate the convenience and efficiency. Nevertheless, additional support may be needed to prevent telehealth from exacerbating health inequities.

Clinical performance and health equity implications of the American Diabetes Association's 2023 screening recommendation for prediabetes and diabetes.

Introduction: The American Diabetes Association (ADA) recommends screening for prediabetes and diabetes (dysglycemia) starting at age 35, or younger than 35 years among adults with overweight or obesity and other risk factors. Diabetes risk differs by sex, race, and ethnicity, but performance of the recommendation in these sociodemographic subgroups is unknown. Methods: Nationally representative data from the National Health and Nutrition Examination Surveys (2015-March 2020) were analyzed from 5,287 nonpregnant US adults without diagnosed diabetes. Screening eligibility was based on age, measured body mass index, and the presence of diabetes risk factors. Dysglycemia was defined by fasting plasma glucose ≥100mg/dL (≥5.6 mmol/L) or haemoglobin A1c ≥5.7% (≥39mmol/mol). The sensitivity, specificity, and predictive values of the ADA screening criteria were examined by sex, race, and ethnicity. Results: An estimated 83.1% (95% CI=81.2-84.7) of US adults were eligible for screening according to the 2023 ADA recommendation. Overall, ADA's screening criteria exhibited high sensitivity [95.0% (95% CI=92.7-96.6)] and low specificity [27.1% (95% CI=24.5-29.9)], which did not differ by race or ethnicity. Sensitivity was higher among women [97.8% (95% CI=96.6-98.6)] than men [92.4% (95% CI=88.3-95.1)]. Racial and ethnic differences in sensitivity and specificity among men were statistically significant (P=0.04 and P=0.02, respectively). Among women, guideline performance did not differ by race and ethnicity. Discussion: The ADA screening criteria exhibited high sensitivity for all groups and was marginally higher in women than men. Racial and ethnic differences in guideline performance among men were small and unlikely to have a significant impact on health equity. Future research could examine adoption of this recommendation in practice and examine its effects on treatment and clinical outcomes by sex, race, and ethnicity.

Screening for Prediabetes and Diabetes in a National Network of Federally Qualified Health Centers: An Observational Study.

BACKGROUND: In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended screening for prediabetes and diabetes among adults aged 35-70 years with overweight or obesity. Studying dysglycemia screening in federally qualified health centers (FQHCs) that serve vulnerable patient populations is needed to understand health equity implications of this recommendation. OBJECTIVE: To investigate screening practices among FQHC patients who would be eligible according to the 2021 USPSTF recommendation. DESIGN: Retrospective cohort study analyzing electronic health records from a national network of 282 FQHC sites. PARTICIPANTS: We included 183,329 patients without prior evidence of prediabetes or diabetes, who had ≥ 1 office visit from 2018-2020. MAIN MEASURES: Screening eligibility was based on age and measured body mass index (BMI). The primary outcome, screening completion, was ascertained using hemoglobin A1c or fasting plasma glucose results from 2018-2020. KEY RESULTS: Among 89,543 patients who would be eligible according to the 2021 USPSTF recommendation, 53,263 (59.5%) were screened. Those who completed screening had higher BMI values than patients who did not (33.0 ± 6.7 kg/m2 vs. 31.9 ± 6.2 kg/m2, p < 0.001). Adults aged 50-64 years had greater odds of screening completion relative to younger patients (OR 1.13, 95% CI: 1.10-1.17). Patients from racial and ethnic minority groups, as well as those without health insurance, were more likely to complete screening than White patients and insured patients, respectively. Clinical risk factors for diabetes were also associated with dysglycemia screening. Among patients who completed screening, 23,588 (44.3%) had values consistent with prediabetes or diabetes. CONCLUSIONS: Over half of FQHC patients who would be eligible according to the 2021 USPSTF recommendation were screened. Screening completion was higher among middle-aged patients, those with greater BMI values, as well as vulnerable groups with a high risk of developing diabetes. Future research should examine adoption of the 2021 USPSTF screening recommendation and its impact on health equity.

Medication Dosing Schedules, Medication Knowledge, and Dosing Errors of Adults Taking Complex Drug Regimens.

This study examined how patients take complex medication regimens at home. Participants were primary care patients, 21 years or older, and prescribed three or more medications. Interviews assessed medication dosing schedules, medication knowledge, and dosing errors. Participants (N=441) were middle aged (mean 56.9); the majority were Hispanic/Latino (73.4%), had limited English proficiency (59.0%), and had limited health literacy (89.0%). One in five participants dosed medication five or more times per day, although no participants in the sample had a label instructing them to take medication more than times times daily. On average, participants correctly identified the purpose of 65% of their medications. Half of participants made one or more dosing errors. Less than high school education and a regimen size of six or more medications were independently associated with less medication knowledge, whereas language discordant label instructions were associated with dosing errors. Screening for regimen dosing complication and interventions to simplify dosing schedules are needed.

Screening for Prediabetes and Diabetes: Clinical Performance and Implications for Health Equity.

INTRODUCTION: In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended prediabetes and diabetes screening for asymptomatic adults aged 35-70 years with overweight/obesity, lowering the age from 40 years in its 2015 recommendation. The USPSTF suggested considering earlier screening in racial and ethnic groups with high diabetes risk at younger ages or lower BMI. This study examined the clinical performance of these USPSTF screening recommendations as well as alternative age and BMI cutoffs in the U.S. adult population overall, and separately by race and ethnicity. METHODS: Nationally representative data were collected from 3,243 nonpregnant adults without diagnosed diabetes in January 2017-March 2020 and analyzed from 2021 to 2022. Screening eligibility was based on age and measured BMI. Collectively, prediabetes and undiagnosed diabetes were defined by fasting plasma glucose ≥100 mg/dL or hemoglobin A1c ≥5.7%. The sensitivity, specificity, and predictive values of alternate screening criteria were examined overall, and by race and ethnicity. RESULTS: The 2021 criteria exhibited marginally higher sensitivity (58.6%, 95% CI=55.5, 61.6 vs 52.9%, 95% CI=49.7, 56.0) and lower specificity (69.3%, 95% CI=65.7, 72.2 vs 76.4%, 95% CI=73.3, 79.2) than the 2015 criteria overall, and within each racial and ethnic group. Screening at lower age and BMI thresholds resulted in even greater sensitivity and lower specificity, especially among Hispanic, non-Hispanic Black, and Asian adults. Screening all adults aged 35-70 years regardless of BMI yielded the most equitable performance across all racial and ethnic groups. CONCLUSIONS: The 2021 USPSTF screening criteria will identify more adults with prediabetes and diabetes in all racial and ethnic groups than the 2015 criteria. Screening all adults aged 35-70 years exhibited even higher sensitivity and performed most similarly by race and ethnicity, which may further improve early detection of prediabetes and diabetes in diverse populations.

Association of Health Literacy and Numeracy With Lupus Knowledge and the Creation of the Lupus Knowledge Assessment Test.

OBJECTIVE: Limited health literacy and numeracy are associated with worse patient-reported outcomes and higher disease activity in systemic lupus erythematosus (SLE), but which factors may mediate this association is unknown. We sought to determine the association of health literacy and numeracy with SLE knowledge. METHODS: Patients with SLE were recruited from an academic center clinic. Participants completed validated assessments of health literacy (Newest Vital Sign [NVS]; n = 96) and numeracy (Numeracy Understanding in Medicine Instrument, Short Version [S-NUMI]; n = 85). They also completed the Lupus Knowledge Assessment Test (LKAT), which consists of 4 questions assessing SLE knowledge that were determined through consensus expert opinion for their wide applicability and importance related to self-management of the disease. Descriptive statistics and multivariable logistic regression modeling were used to analyze the results. RESULTS: In our SLE cohort (n = 125), 33% (32/96) had limited health literacy and 76% (65/85) had limited numeracy. The majority correctly identified that hydroxychloroquine prevented SLE flares (91%); however, only 23% of participants correctly answered a numeracy question assessing which urine protein to creatinine (UPC) ratio was > 1000 mg/g. The mean LKAT score was 2.7 out of 4.0. Limited health literacy, but not numeracy, was associated with lower knowledge about SLE as measured by the LKAT, even after adjusting for education. CONCLUSION: Patients with SLE with limited health literacy had lower knowledge about SLE. The LKAT could be further refined and/or used as a screening tool to identify patients with knowledge gaps. Further work is needed to improve patients' understanding of proteinuria and investigate whether literacy-sensitive education can improve care.

Development and Validation of the Consumer Health Activation Index.

BACKGROUND: Although there has been increasing interest in patient engagement, few measures are publicly available and suitable for patients with limited health literacy. OBJECTIVE: We sought to develop a Consumer Health Activation Index (CHAI) for use among diverse patients. METHODS: Expert opinion, a systematic literature review, focus groups, and cognitive interviews with patients were used to create and revise a potential set of items. Psychometric testing guided by item response theory was then conducted among 301 English-speaking, community-dwelling adults. This included differential item functioning analyses to evaluate item performance across participant health literacy levels. To determine construct validity, CHAI scores were compared to scales measuring similar personality constructs. Associations between the CHAI and physical and mental health established predictive validity. A second study among 9,478 adults was used to confirm CHAI associations with health outcomes. RESULTS: Exploratory factor analyses revealed a single-factor solution with a 10-item scale. The CHAI showed good internal consistency (alpha = 0.81) and moderate test-retest reliability (ICC = 0.53). Reading grade level was found to be at the 6th grade. Moderate to strong correlations were found with similar constructs (Multidimensional Health Locus of Control, r = 0.38, P < 0.001; Conscientiousness, r = 0.41, P < 0.001). Predictive validity was demonstrated through associations with functional health status measures (depression, r = -0.28, P < 0.001; anxiety, r = -0.22, P < 0.001; and physical functioning, r = 0.22, P < 0.001). In the validation sample, the CHAI was significantly associated with self-reported physical and mental health ( r = 0.31 and 0.32 respectively; both P < 0.001). CONCLUSIONS: The CHAI appears to be a valid, reliable, and easily administered tool that can be used to assess health activation among adults, including those with limited health literacy. Future studies should test the tool in actual use and explore further applications.

Literacy disparities in patient access and health-related use of Internet and mobile technologies.

BACKGROUND: Age and race-related disparities in technology use have been well documented, but less is known about how health literacy influences technology access and use. OBJECTIVE: To assess the association between patients' literacy skills and mobile phone ownership, use of text messaging, Internet access, and use of the Internet for health-related purposes. METHODS: A secondary analysis utilizing data from 1077 primary care patients enrolled in two, multisite studies from 2011-2013. Patients were administered an in-person, structured interview. RESULTS: Patients with adequate health literacy were more likely to own a mobile phone or smartphone in comparison with patients having marginal or low literacy (mobile phone ownership: 96.8 vs. 95.2 vs. 90.1%, respectively, P < 0.001; smartphone ownership: 70.6 vs. 62.5 vs. 40.1%, P < 0.001) and to report text messaging (78.6 vs. 75.2 vs. 53.1%, P < 0.001). They were also more likely to have access to the Internet from their home (92.1 vs. 74.7 vs. 44.9%, P < 0.001) and to report using the Internet for email (93.0 vs. 75.7 vs. 38.5%, P < 0.001), browsing the web (93.9 vs. 80.2 vs. 44.5%, P < 0.001), accessing health information (86.3 vs. 75.5 vs. 40.8%, P < 0.001), and communicating with providers (54.2 vs. 29.8 vs. 13.0%, P < 0.001). Relationships remained significant in multivariable analyses controlling for relevant covariates. CONCLUSIONS: Results reveal that literacy-related disparities in technology access and use are widespread, with lower literate patients being less likely to own smartphones or to access and use the Internet, particularly for health reasons. Future interventions should consider these disparities and ensure that health promotion activities do not further exacerbate disparities.

Comparative effectiveness of patient-centered strategies to improve FDA medication guides.

BACKGROUND: Med Guides are the only Food and Drug Administration-regulated source of written patient information distributed with prescriptions drugs. Despite their potential value, studies have found them to have limited utility. OBJECTIVE: To evaluate the effectiveness of patient-centered strategies for the design of Med Guides to improve comprehension. DESIGN: A cross-sectional, randomized trial. SETTING: Two primary care clinics in Chicago, Illinois; one based in a public university hospital and the other within a private academic medical center. PATIENTS: A total of 1003 adults aged 18-85 years. INTERVENTION: The format and layout of content from 3 typical Med Guides (by reading difficulty, length, exposure) were modified several ways to promote information accessibility. Working with patients, the 3 most preferred versions were evaluated. The first used 2 columns to organize content (Column), a second mimicked over-the-counter "Drug Facts" labeling (Drug Facts), and the third followed health literacy best practices using a simple table format (Health Literacy prototype). MEASURES: Tailored comprehension assessment of content from 3 representative Med Guides. RESULTS: Comprehension was significantly greater for all 3 prototypes compared with the current standard (all P<0.001). The Health Literacy prototype consistently demonstrated the highest comprehension scores, and in multivariable analyses, outperformed both the Drug Facts [ß=-4.43, 95% confidence interval (CI), -6.21 to -2.66] and Column (ß=-4.04, 95% CI, -5.82 to -2.26) prototypes. Both older age (older than 60 y: ß=-10.54, 95% CI, -15.12 to -5.96), low and marginal literacy skills were independently associated with poorer comprehension (low: ß=-31.92, 95% CI, -35.72 to -28.12; marginal: ß=-12.91, 95% CI, -16.01 to -9.82). CONCLUSIONS: The application of evidence-based practices to the redesign of Med Guides significantly improved patient comprehension. Although some age and literacy disparities were reduced with the Health Literacy format in particular, both older age and low literacy remained independently associated with poorer comprehension. More aggressive strategies will likely be needed to gain assurances that all patients are informed about their prescribed medications. TRIAL REGISTRATION: Clinical Trials.Gov #NCT01731405.

Disease-related distress, self-care and clinical outcomes among low-income patients with diabetes.

BACKGROUND: The purpose of this study is to determine the prevalence of diabetes distress and its relationship with health behaviours and clinical outcomes in low-income patients. METHODS: Secondary analyses were conducted using baseline data from a clinical trial evaluating a diabetes self-management intervention. Interviews were conducted with 666 participants receiving care at nine safety net clinics in Missouri. Distress was measured using the Diabetes Distress Scale, and outcomes included medication adherence, physical activity, nutrition and clinical biomarkers (haemoglobin A1C (HbA1C), blood pressure, low-density lipoprotein (LDL) cholesterol). RESULTS: In a sample of 666 participants, 14.1% and 27.3% of patients were identified as highly and moderately distressed, respectively, with higher rates among younger, female and lower income patients. When compared with moderately and no distress groups, highly distressed patients were less adherent to medications (20.7% vs 29.9% vs 39.4%, p<0.001) and had higher HbA1C values (9.3% (SD=2.0) vs 8.2% (SD=1.8) vs 7.8% (SD=1.7), p<0.001), diastolic blood pressure (81.8 (SD=9.4) vs 80.2 (9.7) vs 78.9 (SD=8.8), p=0.02) and LDL cholesterol (104.6 (SD=42.4) vs 97.2 (34.3) vs 95.5 (37.9)) In multivariable analyses, high and moderate distress were associated with lower medication adherence (OR=0.44; 0.27 to 0.23, p=0.001) and (OR=0.58; 0.42 to 0.79; p=0.001), respectively, and higher HbA1C in only the highly distressed group (B=1.3; 0.81 to 1.85; p<0.001) compared with the no distress group. CONCLUSIONS: Diabetes distress is prevalent and linked to poorer adherence to health behaviours and glycemic control in a sample of patients receiving care from low-income clinics.