Impact of Integrated Patient-Facing Health IT Tools on Quality and Resource Use for Patients with Diabetes

摘要 这项更新研究将检查面向患者的数字医疗技术的使用如何影响质量和 糖尿病患者的资源利用。利用13年的研究时间(2007-2019年)，我们利用交错的 实施移动应用程序、基于网络的健康计划和患者提供者视频访问 2008-2014年间，在超过200,000名糖尿病患者(持续或新发)中 诊断)。集成的传送系统设置可全面捕获诊断和 所有患者临床医生(初级保健)的治疗数据(包括药物、实验室结果和成像) 和专科医生)，并向患者提供综合数据 门户移动应用程序。我们在最初的研究中成功地检验了临床医生面对的影响 电子健康记录(EHR)，发现与改善糖尿病护理质量有关(增加 指南建议的检测和治疗)和临床结果(改善血糖和血脂控制， 减少急诊室就诊和住院治疗)。这项延期提案将这一调查范围扩大到 包括新的面向患者的技术。我们将研究的所有技术都与 患者持续的医疗保健提供者和更广泛的临床EHR，与不断增长的健康人数形成对比 可供患者下载的应用程序是数据的死胡同，导致医疗保健更加分散。这个 主要建议的研究预测因素是患者技术使用(移动应用程序、基于网络的健康计划、 和患者提供者视频访问)。在目标1中，我们将检查是否使用面向患者的技术 改善糖尿病患者的护理质量，特别是检查遵循指南的处方药 糖尿病和糖尿病的使用和实验室监测、药物依从性和生理性疾病控制(实验室价值) 其他四种慢性疾病(哮喘、冠心病、CHF和HTN)中的任何一种。在目标2中，我们将研究 资源使用结果衡量标准包括门诊就诊、急诊科就诊和非选择性就诊 住院治疗。使用边际结构模型，我们将测试患者使用的技术是 与更高的质量和更低的面对面就诊率相关，同时考虑到患者的参与度， 最近健康状况、病例组合、面对面就诊的费用分摊以及患者人口统计和 社会经济特征。这项拟议的研究很可能是对 面向患者的技术在健康结果上的使用，包括患者-提供者视频访问远程医疗。通过 检查技术的早期采用者，以及具有复杂的临床和自我诊断的糖尿病患者 管理需求，该项目有可能提供及时的证据，以告知新兴的远程医疗和 移动健康政策、技术采用决策以及临床医生和患者的真实使用情况。

SUMMARY This renewal study will examine how use of patient-facing digital health technologies impacts quality and resource use for patients with diabetes. Using a 13 year study period (2007-2019), we exploit the staggered implementation of mobile applications, web-based wellness programs, and patient-provider video-visits between 2008-2014, among a large population of over 200,000 patients with diabetes (ongoing or new diagnoses). The integrated delivery system setting provides comprehensive capture of diagnostic and treatment data (including medications, lab results and imaging) across all of a patient’s clinicians (primary care and specialists) in inpatient and outpatient settings, and make integrated data available to patients through the portal mobile applications. We were successful in our original study examining the impact of clinician-facing electronic health records (EHRs), finding associations with improved diabetes care quality (increases in guideline-recommended testing and treatment), and clinical outcomes (improved blood sugar and lipid control, reductions in emergency room visits and hospitalizations). This renewal proposal extends this line of inquiry to include novel patient-facing technologies. All of the technologies we will examine are well-integrated with patients’ ongoing health care providers and broader clinical EHR, in contrast with the growing number of health applications available for patient download that are a data dead-end, leading to more fragmented care. The main proposed study predictor is patient technology use (mobile applications, web-based wellness programs, and patient-provider video-visits). In Aim 1, we will examine whether use of patient-facing technologies improves quality of care in patients with diabetes, specifically examining guideline-adherent prescription drug use and laboratory monitoring, drug adherence, and physiologic disease control (lab values) for diabetes and for any of four other comorbid chronic conditions (Asthma, CAD, CHF, and HTN). In Aim 2, we will examine resource use outcome measures including outpatient visits, emergency department visits, and non-elective hospitalizations. Using marginal structural models, we will test the hypotheses that patient technology use is associated with improved quality and lower in-person visit rates, while accounting for patient engagement, recent changes in health status, case-mix, cost-sharing for in-person visits, and patient demographic and socio-economic characteristics. The proposed study is likely to be the largest rigorous study of the impact of patient-facing technology use on health outcomes, including patient-provider video visit telehealth. By examining an early adopter of the technologies, and patients with diabetes who have complex clinical and self- management needs, this project has the potential to provide timely evidence to inform emerging telehealth and mhealth policies, technology adoption decisions, and real world use by clinicians and patients.