key: cord-0730526-bty1wckn authors: Cromwell, Grace E.; Hudson, Margo S.; Simonson, Donald C.; McDonnell, Marie E. title: Outreach Method Predicts Patient Re-engagement in Diabetes Care During Sustained Care Disruption date: 2021-09-14 journal: Endocr Pract DOI: 10.1016/j.eprac.2021.09.003 sha: 0041892c340b16c6322de765b9288ff5c67c60a4 doc_id: 730526 cord_uid: bty1wckn OBJECTIVE: During the COVID-19 pandemic, visits for diabetes care were abruptly canceled without predefined procedures to re-engage patients. This study was designed to determine how outreach influences patients to maintain diabetes care, as well as identify factors that may impact efficacy. METHODS: A diabetes nursing team attempted outreach for patients with a canceled diabetes appointment between March 16 and June 19, 2020. Outreach status was defined as reached, message left, or no contact. Outcomes were defined as 1. booking and 2. keeping a follow up appointment. RESULTS: Seven hundred and eighty-seven patients were included (384 (49%) reached, 152 (19%) message left, 251 (32%) no contact). Reached patients were more likely to book (OR=2.43, p<0.001) and keep an appointment (OR=2.39, p<0.001) compared to no contact. Leaving a message did not increase odds of booking (OR=1.05, p=0.84) or keeping (OR=1.17, p=0.568) compared to no contact. Older age was a significant predictor of booking (OR=1.014 for each year older, p=0.037). Patients on insulin were more likely to keep their appointment (OR=1.70, p=0.008). Patients with higher HbA1c were less likely to keep their appointment (OR=0.87 for each 1.0% increase in HbA1c, p=0.011). CONCLUSION: These findings suggest that to optimize re-engagement during care disruption, one-way communication is no better than no contact and two-way communication increases the likelihood that patients will maintain access to care. In addition, while higher risk patients (e.g. older age or on insulin) may be more incentivized to stay engaged, targeted outreach is needed for those with chronically poor glycemic control. Across the globe, the COVID-19 pandemic has caused sustained disruptions in access to usual 24 care, and this had a significant impact on people with diabetes 1,2,3,4 . On January 20 th , 2020, the 25 first case of COVID-19 in the United States was diagnosed in Washington state, and by March 26 2 nd the SARS-CoV-2 virus had been identified in Massachusetts. A pandemic was declared on 27 March 11 th by the World Health Organization and the United States entered a national 28 emergency on March 13 th , 2020 5 . This rapid succession of events led public health officials to 29 advise people to stay at home for mild illness to limit the workload of hospitals and save medical 30 resources for moderate to severe illness. This resulted in a 25-88% decrease in emergency room 31 visits 6, 7, 8 , up to 72% cancelled elective surgeries 9, 10 , and reduced routine care visits 11, 12, 13 . While 32 the decrease in emergency room visits may have been partially due to less opportunity for injury 33 and trauma during the lockdown, it was also thought to be due to patients delaying care 3, 6, 7, 8 . Previous natural disasters and pandemics experienced the same patterns of care disruption and lack of guidance to keep patients engaged throughout. Hurricane Katrina (2005) , Hurricane virtual clinics, the diabetes program launched a patient tracking initiative that temporarily 69 redeployed ambulatory nurses to perform remote outreach. Between March 16 th and June 19 th , 70 2020 (14 weeks), an administrative report (POLR: Physician Online Reporting) was run daily to 71 capture all canceled and scheduled appointments with MD, NP, or RN within the diabetes clinic. Patients who canceled and had not been seen in the clinic within the last month were placed on 73 the Patient Tracker, a sharable workbook, for proactive outreach from the diabetes nursing team. Outreach was conducted by phone and online patient portal messaging for those who had access; 75 interpreter services were used per standard practice for those who did not speak English. logistic regression models were used to determine the association (odds ratios with 95% 90 confidence intervals) between booking an appointment or keeping an appointment and the 91 J o u r n a l P r e -p r o o f outreach status, with adjustment for baseline covariates. Patients were excluded from analysis 92 due to non-pandemic related cancelations. We defined these cancelations by the following 93 criteria: 1) canceled prior to the year 2020 2) canceled due to transferring care elsewhere, or 3) 94 provider rescheduled the clinic to a different date, or 4) there was a notation by staff that the A total of 2,728 patients were identified as having a canceled appointment between March 16 100 and June 19, 2020. Of these, 1,392 were excluded because the appointment was not for diabetes, 101 257 were excluded as duplicate entries, and 292 were excluded because the appointment was 102 canceled for non-pandemic reasons. The remaining 787 patients were determined to have 103 canceled diabetes visits due to the pandemic and were included in this analysis ( Figure 1 ). The mean (SD) age was 61.7 (14.2) Of the 648 patients who booked an appointment, 519 patients (80%) kept their appointment. Similar to the booking outcome, there was no significant difference in keeping an appointment 127 between those who were not contacted (72%) and those who were left a message (75%) (OR = Other factors that clearly influenced re-engagement include age, baseline HbA1c, and insulin 157 use. Older patients were more likely to book with likelihood increasing with each year of age. Patients on insulin were more likely to keep their appointment, perhaps to maintain prescriptions 159 and dosing adjustments. In contrast, patients with a higher baseline HbA1c were less likely to impact that will likely materialize in the next decade 11 . It is also likely that PWD will be 194 significantly impacted by backlogs in surgeries, particularly for foot/lower limb, cardiovascular 195 and musculoskeletal conditions 9 . The reasons why certain patient groups are at higher risk for disengagement are likely complex 212 and multi-dimensional, thus identifying a single approach to maintaining engagement is difficult. As for best practice, interpreters for those who do not speak English are important, as utilized in 214 this study as part of standard care, but a more culturally aligned approach may be required to may not be a sustainable approach for many practices. Future studies should investigate more 226 sustainable approaches such as culturally acceptable, patient-tailored SMS text messaging with a 227 chat bot or a member of the clinical or administrative team. These findings can guide a priori 228 planning which will be vital for future pandemics and outbreaks to keep patients and providers 229 safe while also maintaining routine care throughout. that were clearly not pandemic related, for example the visit was rescheduled to another date or 235 the appointment was booked in error. However, there were other appointments for which the 236 reason had to be assumed as the specific cause was not listed. The number of cancelations due to 237 the pandemic could be inflated due to this. As this was not a randomized or protocol-led study, the outreach team could have biases 240 regarding who they attempted to contact on the list as we did not mandate a specific order of 241 contact on the shared worklist. This made the populations not as random as assumed. Additionally, we did not examine whether different nurses had a differential impact on 243 booking/keeping appointments. We do not know whether the nurse was known to the patient, or 244 if that was more effective than someone not known to the patient. Also, we do not know if 245 administrative staff would have been as successful as the nursing team members. 246 We encouraged the nursing team to use both internet-based portal and telephone outreach 247 methods, as the program was trying to reach the patient by whatever means necessary; however, this means that the two variables cannot be separated. Portal messaging was a significant 249 predictor of booking, but that variable was a mix of portal alone and portal plus telephone. It is 250 impossible based on this data to determine the sole impact of portal vs telephone outreach. In addition, it can be speculated that portal access may identify patients more capable of 252 navigating the challenges of virtual care and thus were more engaged by our standards. Additionally, while portal access may indicate that the patient can navigate these challenges, 254 these data are unable to indicate which factor is more significant, access to portal or the 255 messaging outreach itself. Finally, we were only able to report associations between intervention and outcome. We do not 257 report causation, i.e., the outreach caused the patient to book and keep their appointment. 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Are blood sugars stable? Does the patient have access to Patient Gateway? Y/N Would patient be interested in Video Virtual visits? Y/N Plan for sharing glucose or other data with their care team: Assessment/Plan: Orders placed today: Future appointments scheduled? Cc We would like to acknowledge the tireless work of the BWH Diabetes Program nursing team The authors declare no conflict of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.