Publications

This prospective cohort study sought to identify predictors of functional decline in patients aged 65 years or older who underwent major, nonemergent abdominal or thoracic surgery in our tertiary hospital from 2006 to 2008. We used the Stanford Health Assessment Questionnaire-Disability Index (HAQ-DI) to evaluate functional decline; a 0.1 or greater increase was used to indicate a clinically significant decline. The preoperative Duke Activity Status Index (DASI) and a physical function score (PFS), assessing gait speed, grip strength, balance, and standing speed, were evaluated as predictors of decline. We enrolled 215 patients (71.2 ± 5.2 years; 56.7% female); 204 completed follow-up HAQ assessments (71.1 ± 5.3 years; 57.8% female). A significant number of patients had functional decline out to 1 year. Postoperative HAQ-DI increases of 0.1 or greater occurred in 45.3 per cent at 1 month, 30.1 per cent at 3 months, and 28.3 per cent at 1 year. Preoperative DASI and PFS scores were not predictors of functional decline. Male sex at 1 month (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.41 to 6.85); American Society of Anesthesiologists class (OR, 3.41; 95% CI, 1.31 to 8.86), smoking (OR, 3.15; 95% CI, 1.27 to 7.85), and length of stay (OR, 1.09; 95% CI, 1.01 to 1.16) at 3 months; and cancer diagnosis at 1 year (OR, 2.6; 95% CI, 1.14 to 5.96) were associated with functional decline.

OBJECTIVES

Secure messaging and phone encounters are becoming widespread to increase patient access to providers between ambulatory care visits. Although these encounters have the potential to improve the control of diabetes risk factors,we know little about their content in relation to traditional in-person visits.

STUDY DESIGN

Cross-sectional analysis of survey and electronic health record data of patients with diabetes receiving care at Group Health Cooperative in 2008 to 2009.

METHODS

The primary outcome was patient-reported communication with their providers about risk factors for diabetes complications (glucose, blood pressure [BP], and cholesterol) during in-person, phone, and secure messaging encounters. Additional variables included patient demographic, health, and utilization characteristics. We examined unadjusted associations with reported communication by risk factor, encounter type, and demographic/health characteristics.

RESULTS

Among 569 patients, 50% were aged ≥ 65 years, 50% were male, 35% had ≥ college education, and 64% were white; 77% had ≥ 1 between-visit encounter (63% phone, 41% secure messaging). Discussions about glucose were reported by 89% during in-person visits and 42% during between-visit encounters compared with 81% and 17% for BP and 76% and 20% for cholesterol (all P < .001). Those who were younger, more educated, of black or other race/ethnicity, on insulin, or in poor control of glycated hemoglobin were more likely to report risk factor discussions during between-visit encounters.

CONCLUSIONS

In this system, patients with diabetes reported significantly fewer risk factor discussions during between-visit encounters compared with in-person visits. These results suggest potential missed opportunities for proactive support of risk factor management.