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Patient-centered communication (PCC) plays a vital role in effective cancer management and care. Patient portals are increasingly available to patients and hold potential as a valuable tool to facilitate PCC. However, whether more frequent use of patient portals is associated with increased perceived PCC and which mechanisms might mediate this relationship have not been fully studied.
The goal of this study was to investigate the association between the frequency of access of patient portals and perceived PCC in patients diagnosed with cancer. We further sought to examine whether this association was mediated by patients’ self-efficacy in health information–seeking.
We used data from the Health Information National Trend Survey 5 (HINTS 5) cycle 3 (2019) and cycle 4 (2020). This analysis includes 1222 individuals who self-reported having a current or past diagnosis of cancer. Perceived PCC was measured with a 7-item HINTS 5–derived scale and classified as low, medium, or high. Patient portal use was measured by a single item assessing the frequency of use. Self-efficacy about health information–seeking was assessed with a 1-item measure assessing confidence in obtaining health information. We used adjusted multinomial logistic regression models to estimate relative risk ratios (RRRs)/effect sizes of the association between patient portal use and perceived PCC. Mediation by health information self-efficacy was investigated using the Baron and Kenny and Karlson-Holm-Breen methods.
A total of 54.5% of the sample reported that they had not accessed their patient portals in the past 12 months, 12.6% accessed it 1 to 2 times, 24.8% accessed it 3 to 9 times, and 8.2% accessed it 10 or more times. Overall, the frequency of accessing the patient portal was marginally associated (
Increased frequency of patient portal use was associated with higher PCC, and an individual’s health information–seeking self-efficacy partially mediated this association. These findings emphasize the importance of encouraging patients and providers to use patient portals to assist in patient-centeredness of cancer care. Interventions to promote the adoption and use of patient portals could incorporate strategies to improve health information self-efficacy.
Approximately 17 million people in the United States are living with cancer [
Patient-centered care comprises multiple factors, and patient-centered communication (PCC) is an essential aspect [
Much research promoting PCC in cancer care has focused on assessing and improving clinicians’ skills and training. Less work, however, has been done on patient-specific characteristics such as a patient’s ability to seek information [
Health information self-efficacy is a personal belief that one can take action to get the information if they need it regarding a health concern [
The purpose of this study was to assess the association between the frequency of access to patient portals and perceived PCC in a national sample of individuals who have had a diagnosis of cancer. We further sought to determine whether self-efficacy related to information-seeking mediated the relationship between frequency of access to patient portals and PCC. We hypothesized that greater frequency of portal access would be associated with high PCC and that health information self-efficacy mediates the relationship between portal use frequency and PCC.
Data examined for this study were from the Health Information National Trends Survey (HINTS). HINTS is a cross-sectional survey that the National Cancer Institute has regularly administered since 2004. HINTS aims to assess how people access and use health information, how people use information technology to manage health and health information, and the degree to which people are engaged in healthy behaviors [
This study combines the third and fourth data collection cycles for HINTS 5. HINTS 5 cycle 3 was conducted from January 22 to April 30, 2019, and it consisted of data from 3500 respondents using a mailed survey. The response rate for the mailed survey was 30.2%. During HINTS 5 cycle 3, a web pilot test was run alongside the self-administered mailed version from January 29 to May 7, 2019. The web pilot comprised 2046 additional respondents. The web-based pilot included an experiment testing the effectiveness of offering a $10 Amazon gift card for responding via the web. Web pilot respondents who were offered the bonus incentive had a slightly higher response rate (31.5%) compared to the control group (29.6%), who did not receive the Amazon gift card [
This study qualified for exempt status from the Committee for the Protection of Human Subjects at the University of Massachusetts Chan Medical School.
Use of patient portals was measured by the question: How many times did you access your online medical record in the last 12 months? We categorized this as no use, 1 to 2 times, 3 to 9 times, and 10 or more times during the last 12 months. Online medical records are accessed with the help of patient portal secure log-ins [
Perceived PCC was assessed with 7 items. Participants asking about communication with all health professionals were asked to assess the frequency with which their providers engaged in the following behaviors in the past 12 months: Give you the chance to ask all the health-related questions you had? Give the attention you need to your feelings and emotions? Involve you in decisions about your health care as much as you wanted? Make sure you understood the things you needed to do to take care of your health? Explain things in a way you could understand? Spend enough time with you? Help you deal with feelings of uncertainty about your health or health care? All items were measured on a 4-point Likert scale ranging from always (1) to never (4).
To create the PCC score, items were reverse coded so that higher numbers reflected higher levels of communication. The mean of all 7 items is transformed to a linear scale ranging from 1 to 100 [
The mediating variable was health information–seeking self-efficacy. We hypothesized that it mediated the relationship between frequency of portal use and perceived PCC. Self-efficacy in seeking health information was measured using 1 item used in previous studies [
Our analysis is adjusted for gender (male, female), age (<55 years, 55 to 64 years, 65 to 74 years, 75 years and older), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian/other), income level (<$35,000, $35,000-$99,999, ≥$100,000), education level (less than high school, high school graduate, some college, college graduate or more), and health insurance status (private, Medicare, Medicaid, or dual coverage). Previous research has shown that these variables have an impact on access and use of patient portals [
All analyses used Taylor series variance estimation with HINTS sampling weights to produce nationally representative estimates as suggested in HINTS methodology guides [
The analytic sample with complete data responses included 1222 respondents, 661 from HINTS 5 cycle 3 and 561 from HINTS 5 cycle 4. As shown in
Characteristics and differences in portal use among respondents with a self-reported cancer diagnosis in the Health Information National Trends Survey cycles 3 and 4 (n=1222 weighted percentages)a.
Characteristic | Total sample, % | Portal use in the past 12 months, % | |||||
|
|
No use | 1-2 times | 3-9 times | ≥10 times | ||
|
—b | — | — | — | — | .31 | |
|
Male | 45.4 | 50.9 | 17.2 | 23.5 | 8.4 | — |
|
Female | 54.6 | 55.5 | 9.8 | 26.3 | 8.3 | — |
|
— | — | — | — | — | <.001 | |
|
<55 | 26.5 | 52.0 | 11.5 | 29.7 | 6.9 | — |
|
55-64 | 22.6 | 41.1 | 15.6 | 25.6 | 17.8 | — |
|
65-74 | 24.0 | 49.6 | 17.5 | 25.6 | 7.3 | — |
|
≥75 | 26.9 | 71.7 | 5.1 | 20.2 | 2.9 | — |
|
— | — | — | — | — | .02 | |
|
Non-Hispanic White | 77.0 | 46.5 | 16.0 | 27.1 | 10.4 | — |
|
Non-Hispanic Black | 7.4 | 77.1 | 7.7 | 8.7 | 6.5 | — |
|
Hispanic | 10.8 | 66.2 | 6.8 | 25.7 | 1.4 | — |
|
Non-Hispanic Asian/other | 4.9 | 54.1 | 8.5 | 34.2 | 3.2 | — |
|
— | — | — | — | — | .03 | |
|
<35,000 | 41.2 | 64.9 | 7.9 | 18.8 | 8.5 | — |
|
35,000-99,999 | 39.7 | 49.9 | 15.1 | 27.5 | 7.5 | — |
|
>100,00 | 19.1 | 41.6 | 17.5 | 32.0 | 9.0 | — |
|
— | — | — | — | — | <.001 | |
|
Less than high school | 7.9 | 76.5 | 1.2 | 21.9 | 0.4 | — |
|
High school graduate | 22.2 | 61.6 | 10.3 | 21.7 | 6.5 | — |
|
Some college | 42.6 | 58.6 | 10.5 | 21.5 | 9.4 | — |
|
College graduate or higher | 27.3 | 34.1 | 21.6 | 34.2 | 10.2 | — |
|
— | — | — | — | — | .17 | |
|
Private (employer or purchased on own) | 56.3 | 50.1 | 15.8 | 25.5 | 8.7 | — |
|
Medicare and privately purchased insurance | 8.8 | 55.0 | 11.2 | 28.8 | 5.1 | — |
|
Medicare | 25.0 | 62.0 | 8.2 | 24.7 | 5.1 | — |
|
Medicaid | 7.9 | 54.0 | 8.8 | 15.7 | 21.5 | — |
|
Other/IHSc/VAd/Tricare | 2.0 | 82.3 | 4.3 | 13.4 | 0 | — |
|
— | — | — | — | — | .21 | |
|
<1 | 15.9 | 48.8 | 12.3 | 25.0 | 13.9 | — |
|
2-5 | 21.2 | 47.9 | 11.7 | 24.8 | 15.5 | — |
|
6-10 | 15.5 | 60.9 | 10.2 | 21.6 | 7.3 | — |
|
≥11 | 47.4 | 53.5 | 13.5 | 28.8 | 4.2 | — |
|
— | — | — | — | — | .19 | |
|
Low (<25th percentile) | 26.5 | 61.2 | 15.0 | 20.5 | 3.4 | — |
|
Moderate (25th-50th percentile) | 24.5 | 53.0 | 10.6 | 29.5 | 7.1 | — |
|
High (≥50th percentile) | 49.1 | 51.7 | 12.2 | 24.8 | 11.3 | — |
|
— | — | — | — | — | .006 | |
|
Somewhat/a little/not at all | 37.4 | 63.0 | 13.0 | 20.7 | 3.3 | — |
|
Completely/very | 62.6 | 48.8 | 12.5 | 27.6 | 11.1 | — |
aAll analyses used Taylor Series variance estimation with Health Information National Trends Survey sampling weights to produce nationally representative estimates.
bNot applicable.
cIHS: Indian Health Service.
dVA: Veterans Affairs.
Results of the multinomial model assessing the association between frequency of portal use and perceived PCC are presented in the middle column of
Results of adjusted multinomial logistic regression models measuring the association of frequency of online access to patient portals with perceived patient-centered communication scorea.
Characteristic | Without adjustment for health information–seeking self-efficacy | With adjustment for health information–seeking self-efficacy | ||||||
|
Moderate vs low PCCb, RRRc (95% CI) | High vs low PCC, RRR (95% CI) | Moderate vs low PCC, RRR (95% CI) | High vs low PCC, RRR (95% CI) | ||||
|
—d | — | .06 | — | — | .25 | ||
|
None | — | — | — | — | — | — | |
|
1-2 times | 0.99 (0.42-2.34) | 1.14 (0.49-2.64) | — | 0.94 (0.39-2.23) | 0.94 (0.38-2.32) | — | |
|
3-9 times | 2.22 (1.01-4.86) | 1.67 (0.88-3.16) | — | 2.01 (0.91-4.48) | 1.31 (0.67-2.56) | — | |
|
≥10 times | 2.91 (0.89-9.49) | 3.63 (1.58-8.34) | — | 2.49 (0.78-8.02) | 2.32 (1.03-5.23) | — | |
|
— | — | — | — | — | <.001 | ||
|
Somewhat/a little/not at all | — | — | — | 1.78 (0.97-3.26) | 4.57 (2.57-8.12) | — | |
|
Completely/very high | — | — | — | 1.78 (0.97-3.26) | 4.57 (2.57-8.12) | — |
aAll analyses adjust for gender, age, race/ethnicity, income level, education level, health insurance status, and time since diagnosis.
bPCC: patient-centered communication.
cRRR: relative risk ratio.
dNot applicable.
The 4-step Baron and Kenny method was first used to investigate the role of health information–seeking self-efficacy as a mediator of the association between frequency of patient portal use and PCC [
These findings led to a more formal mediation analysis using the Karlson-Holm-Breen method, presented in
Mediation results of communication scores using the Karlson-Holm-Breen method.
Characteristic | Odds ratio (95% CI) | Confounding ratio | Mediated proportion (indirect/total) | |||||
|
||||||||
|
None | —a | — | — | ||||
|
|
— | –0.25 | 1.07 | ||||
|
|
Total effect | 1.02 (0.43-2.43) | — | — | |||
|
|
Direct effect | 0.94 (0.39-2.23) | — | — | |||
|
|
Indirect effect | 1.09 (0.92-1.28) | — | — | |||
|
|
— | 1.15 | 0.5 | ||||
|
|
Total effect | 2.23 (1.08-4.63) | — | — | |||
|
|
Direct effect | 2.01 (0.97-4.16) | — | — | |||
|
|
Indirect effect | 1.11 (0.93-1.33) | — | — | |||
|
≥ |
— | 1.22 | 0.4 | ||||
|
|
Total effect | 3.05 (1.02-9.10) | — | — | |||
|
|
Direct effect | 2.49 (0.82-7.55) | — | — | |||
|
|
Indirect effect | 1.22 (0.95-1.58) | — | — | |||
|
||||||||
|
None | — | — | — | ||||
|
|
— | –2.63 | 1.06 | ||||
|
|
Total effect | 1.17 (0.49-2.81) | — | — | |||
|
|
Direct effect | 0.94 (0.39-2.28) | — | — | |||
|
|
Indirect effect | 1.24 (0.85-1.81) | — | — | |||
|
|
— | 2 | 0.76 | ||||
|
|
Total effect | 1.73 (0.89-3.33) | — | — | |||
|
|
Direct effect | 1.31 (0.68-2.54) | — | — | |||
|
|
Indirect effect | 1.31 (0.89-1.93) | — | — | |||
|
≥ |
— | 1.63 | 0.43 | ||||
|
|
Total effect | 3.95 (1.63-9.59) | — | — | |||
|
|
Direct effect | 2.32 (0.94-5.72) | — | — | |||
|
|
Indirect effect | 1.70 (1.11-2.60) | — | — |
aNot applicable.
This study examined the association between the frequency of patient portal use and perceived PCC in patients diagnosed with cancer. We also investigated health information–seeking self-efficacy as a mediator of this association. Our findings indicated that the frequent levels of patient portal use (≥10 times in the past year) may be correlated with high levels of PCC. We also found that this association was partially mediated by health information–seeking self-efficacy.
In cancer care delivery, patient portal use has been increasing [
The provider’s role is critical in establishing PCC, and patient portals are intended to enhance, not replace, patient-provider face-to-face interactions [
Although there was a strong association between high use of patient portals and PCC in this study, only a small proportion of the included sample were frequent users of patient portals, and more than half of the sample reported no patient portal use. The greatest proportion of those with no portal use were females, participants in the 75 years and older age group, non-Hispanic Black participants, in households with <$35,000 per year in income, and participants who reported to have had less than a high school education (76.5%). Our findings are consistent with prior research on these sociodemographic differences except for gender, where males were reported to be less likely to use patient portals in previous studies [
Our analysis further confirms that a significant digital divide persists in actively getting patients to engage with patient portals, as previously reported [
This analysis also demonstrated that health information–seeking self-efficacy partially mediates the association between patient portal use and PCC. Hence, our findings suggest that enhancing self-efficacy in portal use is an important intervention target. It is increasingly emphasized to incorporate user perspectives in health information technology designs [
It is crucial to consider that enhancing portal use is not only dependent on increasing competencies such as knowledge and skills but also on aligning with patient needs and live experiences. To meet these needs, user input is required in designing patient portals in specific populations dealing with distinct health care needs [
Limitations of our study include the use of self-reported data and the cross-sectional design. There is the possibility of recall bias in the frequency and use of patient portals, and the design precludes causal inference. Specifically, we cannot infer whether increased portal use causes increased PCC and vice versa [
Concerning the generalizability of this study, HINTS weights only reflect certain demographic characteristics of the US population and do not take into consideration other factors that may influence individuals electing to participate in the study, which hypothetically could include factors such as greater motivation related to health and health-related constructs. The study sample includes a mix of patients with recent (<15% diagnosed less than a year ago) and distant (approximately 50% diagnosed ≥11 years ago) cancer diagnoses. Hence our results are not generalizable to more recently diagnosed patients. We also combined non-Hispanic Asians/others as our numbers in each category were too low to keep separate. Hence we could not point toward any differences based on race or ethnicity. Likewise, we were unable to compare our sample to a similar national sample of cancer survivors with respect to sociodemographic profile as these data do not exist. Last, we used the term patient portals in this paper as it is a more widely known term and most online records can be accessed via secure patient portal sign-ins. However, online medical records and patient portals could refer to different types of systems, and we cannot ascertain to which the participants were referring.
In summary, PCC is a vital part of quality cancer care. Findings from this national survey suggest that increased frequency of patient portal use is associated with higher PCC and that an individual’s health information–seeking self-efficacy partially mediates this association. While the results of this study need to be replicated in future longitudinal studies, these findings suggest that interventions to encourage the adoption and use of patient portals could incorporate strategies to improve health information self-efficacy and lead to improved PCC.
Health Information National Trends Survey
National Cancer Institute
National Institutes of Health
patient-centered communication
relative risk ratio
MZ is supported by grant T32 CA172009 from the National Cancer Institute (NCI). DA is supported by the grant KL2TR001455 from the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH). SCL, RSS, EA, MIF, and JMF are supported by grant 1K12HK138049-01 from the National Heart, Lung, and Blood Institute. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH, NCI, US Department of Veterans Affairs, or the US Government. The authors are thankful to the NCI Health Information National Trends Survey (HINTS) investigators for their commitment to data collection and making it publicly available, and NCI HINTS participants for their participation in this research.
None declared.