We first computed the proportion of patients with each encounter type in the past year (in-person, phone, secure message, or any between-visit encounter). We then computed the proportion who reported discussing each diabetes risk factor with their provider by encounter type, and compared the proportions with χ² tests. In addition, we compared the proportions reporting discussions across risk factors (eg, glucose vs blood pressure, glucose vs cholesterol), also using χ² tests. Next, we described the amount of overlap in discussions by encounter type—that is, reports of risk factor communication only at in-person visits, only during between-visit encounters, during both, or during neither.

We then analyzed patient demographics and health characteristics by encounter type and by self-reported risk factor communication. First, we examined the percent of respondents with any between-visit encounter by various patient demographics (eg, gender, age, education) and health characteristics (eg, insulin use, control of A1C, blood pressure, and LDL), comparing groups using χ² tests. For example, we compared the percentages with a between-visit encounter among men and women. We then limited the analysis to those with at least 1 between-visit encounter and compared those reporting any between-visit risk factor discussions by the same patient and health characteristics. For example, we compared the percentages of men versus women reporting any between-visit risk factor discussions with their provider. Because our goal was to describe patterns within these crosssectional data, we completed unadjusted analyses.

RESULTS

The longer, written version of the survey had a 68% response rate (592 of the 873 eligible individuals without language, hearing/vision, or other impairments). Our final analysis sample included the 501 patients (57% of those eligible) who answered the risk factor communication outcomes of interest and who gave permission to access their EMR data. Overall, more than three-fourths (77%) of these respondents had a between-visit encounter in the preceding year. There was an average of 8.3 in-person visits (primary and specialty care), compared with 3.1 phone visits (among the 63% who had any phone encounters), and 7.1 secure message encounters (among the 41% who messaged with providers, counting a single secure message encounter as 1 e-mail thread22). In addition, half of the respondents were 65 years or older, half were male, 35% had a college education or more, and 64% were white (Table 1). Half of respondents were on insulin therapy and had on average 1.1 diabetes complications (standard deviation = 1.3). In terms of intermediate diabetes outcomes, 33% of patients had A1C <7%, 43% had blood pressure <130/80 mm Hg, and 73% had LDL <100 mg/dL; 13% were in control of all 3 risk factors simultaneously. Survey non-respondents (also shown in Table 1) were more likely to be younger, more educated, and non-white, without secure message use in the previous year; however, there were no significant differences in non-response to the communication outcomes of interest by granting permission to view medical records or by clinical control of A1C, BP, or LDL.

There were high reports of communication about all 3 diabetes risk factors at in-person visits: 89%, 81%, and 76% reported communication about glucose, blood pressure, and cholesterol, respectively (Figure 1). These discussions were significantly lower during between-visit encounters: 42%, 17%, and 20% reported communication about glucose, blood pressure, and cholesterol, respectively (all P <.001, comparing proportions in person vs between visit by risk factor). Within each encounter type, there was also significantly more reported discussion about glucose as opposed to blood pressure and lipid control (all P <.01). When examining the reported risk factor discussions across all encounter types (Figure 2), the majority (61%-70%) of the patient-provider conversations occurred only during in-person visits. However, 32% reported discussing glucose, 13% reported discussing blood pressure, and 12% reported discussing cholesterol during both in-person and between-visit encounters.

Respondents were more likely to have a between-visit encounter if they had higher in-person utilization, higher diabetes severity, or were using insulin (Table 2). Those with between-visit encounters also had better A1C control, but worse LDL control. When examining reported risk factor communication during these between-visit encounters (Table 3), older and less-educated patients reported less between-visit communication, while those with more in-person visits, insulin use, and in poor control of their A1C were more likely to report risk factor discussions during betweenvisit encounters. Sensitivity analyses examining risk factor communication by each encounter type (not shown) found that those with poorer control of A1C, blood pressure, and LDL reported significantly more discussions during phone visits, but not secure message encounters. Finally, there were different patterns by race: compared with whites, black and other race/ethnicity respondents reported more risk factor communication during between-visit encounters, while Asian patients reported less. Upon further examination, 94% of secure message users and 57% of phone-visit users who were black reported risk factor communication during between-visit encounters, compared with only 53% and 35% of white respondents.

DISCUSSION

To our knowledge, this study was the first examination of patient-provider diabetes risk factor communication patterns across all encounter types. A majority of the sample (77%) had a phone or secure message encounter in this integrated delivery system, suggesting that these encounters are a regular part of care. Overall, more than three-fourths of patients with diabetes reported discussing their diabetes risk factors at inperson visits, but substantially fewer patients reported these discussions during phone or secure message encounters. In addition, the majority of respondents reported discussing risk factors only during in-person visits, even though almost 80% had a phone or secure message encounter in the same time period. Finally, there appeared less discussion about blood pressure and cholesterol compared with glucose (consistent with previous evidence²³), despite standards to focus on all 3 risk factors to prevent micro- and macro-vascular complications.²⁴