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Design and Participants: This retrospective cohort study at Kaiser Permanente Colorado of adults with serious illness who died between 2016 and 2019 examined the association between portal use and end-of-life (EOL) outcomes in the last year of life. Patients were categorized into care groups as follows: care group 1—healthy; care group 2—chronic conditions; care group 3—advanced illness; and care group 4—end of life. Care groups 2-4 were included. Portal use was categorized into engagement types: no use, nonactive, active without a provider, and active with a provider. End-of-life outcomes were hospitalizations in the month before death, last-year advance directive completion, and hospice use. An association between end-of-life outcomes and levels of portal use was assessed using X2 and generalized linear models.
Results: Participants (N=6,517) were aged mean 77 years (SD=14), 50% female, and 84% White and 89% non-Hispanic; 79% had a comorbidity score of 3 or more, 64% were in care group 4, and 99% lived in metropolitan areas. Hospitalizations increased with portal use: nonactive use (relative risk=1.06 [95% CI=0.917-1.23]); active use without provider (1.23 [1.06-1.44]); and active use with provider (1.08 [0.954-1.22]). Advance directive completion also increased with portal use: nonactive use (odds ratio=1.54 [1.12-2.12]); active use without provider (1.13 [0.796-1.59]); and active use with provider (1.38 [1.07-1.77]). Lastly, hospice use increased when used actively with provider (odds ratio=1.01 [0.620-1.65]) but otherwise decreased: nonactive use (0.493 [0.254-0.957]); active use without provider (0.560 [0.271-1.16]).
Commentary: This study found an association between increased portal utilization and increased hospitalizations in the last month of life, recognizing limitations to generalizability (including over a third of patients who died within the study period being excluded due to lack of portal registration). As discussed, this finding warrants additional investigation into the promotion of meaningful portal usage and what we in palliative care would consider to be meaningful. For example, these authors defined a positive EOL outcome as advance directive completion and hospice utilization. This definition excludes those whose goals were concordant with life prolongation, for whom hospitalization at EOL may have been a positive EOL outcome. The authors rightfully highlight disparities in EOL outcomes associated with rurality, lower neighborhood socioeconomic characteristics, and racial/ethnic minority backgrounds.
Bottom Line: The potential association of increased portal usage with hospitalization at EOL highlights opportunities to better leverage meaningful communication access points with seriously ill patients, especially those who are underserved.
Reviewer: Gabrielle Langmann, MD MS, University of Utah, Salt Lake City, UT
References:
1. US Department of Health and Human Services. HITECH Act Enforcement Interim Final Rule. Published October 30, 2009. Accessed February 27, 2025. https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html.
2. Dickman Portz J, Powers JD, Casillas A, et al. Characteristics of patients and proxy caregivers using patient portals in the setting of serious illness and end of life. J Palliat Med. 2021;24(11):1697-1704.
Source: Wan S, Powers JD, Kutner JS, Fischer S, Knoepke CE, Portz JD. Association between patient portal activities and end-of-life outcomes among deceased patients in the last 12 months of life. J Palliat Med. 2024;27(7):916-921. doi:10.1089/jpm.2023.0610.
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