Functional impairment and Internet use among older adults: implications for meaningful use of patient portals

Letters Discussion | In a decade with increasing emphasis and account- ability for glycemic control and cardiovascular risk manage- ment among patients with diabetes, we found that patients with diabetes have experienced a disproportionate reduction in in-hospital mortality over time and a complete reversal in risk of mortality relative to patients without diabetes. This in- teresting trend warrants additional study to elucidate its ori- gins. Potential explanations include coincident improve- ments in inpatient glycemic control, improvements in outpatient glycemic control, improved nonglycemic cardio- vascular risk management among patients with diabetes, and/or advances in therapies for diseases that disproportion- ately affect patients with diabetes. Neel M. Butala, AB Benjamin K. Johnson, MA James D. Dziura, PhD Jesse S. Reynolds, MS Thomas J. Balcezak, MD, MPH Silvio E. Inzucchi, MD Leora I. Horwitz, MD, MHS 2. Fraze T, Jiang HJ, Burgess J. Hospital Stays for Patients with Diabetes, 2008: Statistical Brief #93. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Health Care Policy and Research; 2010. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb93.pdf. Accessed November 3. Holman N, Hillson R, Young RJ. Excess mortality during hospital stays among patients with recorded diabetes compared with those without diabetes. Diabet Med. 2013;30(12):1393-1402. 4. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl 1):S14-S80. 5. Cleeman J, Grundy S, Becker D, Clark L; Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497. 6. Patel A, MacMahon S, Chalmers J, et al; ADVANCE Collaborative Group. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet. 2007;370(9590):829-840. Author Affiliations: Medical student at Yale School of Medicine, New Haven, Connecticut (Butala); Yale Center for Analytical Sciences, School of Public Health, Yale University, New Haven, Connecticut (Johnson, Dziura, Reynolds); Yale–New Haven Hospital, New Haven, Connecticut (Balcezak); Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut (Balcezak, Horwitz); School of Public Health, Yale University, New Haven, Connecticut (Balcezak); Section of Endocrinology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut (Inzucchi); Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut (Horwitz). Corresponding Author: Leora I. Horwitz, MD, MHS, Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, PO Box 208093, New Haven, CT 06520-8093 (leora.horwitz@yale.edu). Published Online: May 19, 2014. doi:10.1001/jamainternmed.2014.1803. Author Contributions: Dr Horwitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Butala, Balcezak, Horwitz. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Butala, Dziura, Reynolds, Horwitz. Critical revision of the manuscript for important intellectual content: Butala, Johnson, Dziura, Reynolds, Balcezak, Inzucchi. Statistical analysis: Johnson, Dziura, Reynolds, Horwitz. Obtained funding: Horwitz. Administrative, technical, or material support: Butala, Balcezak, Horwitz. Study supervision: Balcezak, Inzucchi, Horwitz. Conflict of Interest Disclosures: Dr Inzucchi serves on a Data Safety Monitoring Board for Novo Nordisk, a manufacturer of insulin products used in the hospital setting. No other disclosures are reported. Funding/Support: Dr Horwitz is supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. Role of the Sponsors: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: The authors thank the Yale–New Haven Hospital diabetes management team: Gael Ulisse, APRN, Helen Psarakis, APRN, Anne Kaisen, APRN, and the Yale Endocrine Fellows, for providing high-quality clinical care to the patients in this study, and Janis Bozzo, MSN, RN, Decision Support, Yale–New Haven Health System, for assistance in obtaining study data. None of these individuals received compensation for their contribution. 1. Boyle JP, Honeycutt AA, Narayan KM, et al. Projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the U.S. Diabetes Care. 2001;24(11):1936-1940. Functional Impairment and Internet Use Among Older Adults: Implications for Meaningful Use of Patient Portals Medicare is currently dispensing $30 billion in incentives to health care facilities that adopt the use of electronic medical records (EMRs). In 2014, incentives for “meaningful use” of EMRs will require online access by patients, and reimburse- ment penalties of up to 5% for nonadoption will begin in 2015. 1 Broader use of online patient portals to EMRs is intended to improve care coordination; yet the impact of common prob- lems in Medicare-eligible patients, such as chronic illness or functional impairment, on Internet use is unknown. Methods | This study was approved by the institutional review board for the University of California, San Francisco. We used the Health and Retirement Study (http://hrsonline.isr.umich .edu), a nationally representative sample of community- dwelling seniors (limited to Medicare-eligible individuals aged ≥65 years, excluding the 3%-6% of all Medicare patients who live in nursing homes), for cross-sectional analysis of Inter- net use at 2 time points, 2002 and 2010 (Table). Information regarding informed consent is available at the Health and Re- tirement Study website. We performed descriptive statistics (χ 2 or t test) and multivariable regression analysis (modified Poisson) to characterize features of Internet use at each time point. Results | Overall rates of Internet use doubled from 2002 through 2010 (from 21% to 42%); however, changes in use differed by demographic and health characteristics. Overall, groups with the lowest rates showed the largest relative increases from 2002 through 2010: those with less than a high school education (from 4% to 9%), nonwhite race (from 7% to 21%), functional impairment (from 10% to 23%), poor or fair self-rated health (from 11% to 25%), age 75 years or older (from 12% to 27%), un- partnered status (from 12% to 29%), and any chronic condi- tion (from 19% to 40%) (Table). JAMA Internal Medicine July 2014 Volume 174, Number 7 Copyright 2014 American Medical Association. All rights reserved. jamainternalmedicine.com