Urmimala Sarkar

Beverly Hospital, Boston MA, Beverly, Massachusetts, United States

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Publications (53)171.05 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Consumer health technologies can educate patients about diabetes and support their self-management, yet usability evidence is rarely published even though it determines patient engagement, optimal benefit of any intervention, and an understanding of generalizability. Therefore, we conducted a narrative review of peer-reviewed articles published from 2009 to 2013 that tested the usability of a web- or mobile-delivered system/application designed to educate and support patients with diabetes. Overall, the 23 papers included in our review used mixed (n = 11), descriptive quantitative (n = 9), and qualitative methods (n = 3) to assess usability, such as documenting which features performed as intended and how patients rated their experiences. More sophisticated usability evaluations combined several complementary approaches to elucidate more aspects of functionality. Future work pertaining to the design and evaluation of technology-delivered diabetes education/support interventions should aim to standardize the usability testing processes and publish usability findings to inform interpretation of why an intervention succeeded or failed and for whom.
    Current Diabetes Reports 10/2014; 14(10):534. · 3.17 Impact Factor
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    ABSTRACT: Background: Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis.Methods: As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005. The focus groups included questions about the process of diagnosis, specific factors contributing to missed diagnosis, use of guidelines, atypical vs. typical presentations of disease, diagnostic tools, and follow-up, all with regard to delays in the diagnostic process. The interviews were analyzed (1) deductively, with application of the Systems Engineering Initiative for Patient Safety (SEIPS) model, which addresses systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes, and (2) inductively, with identification of novel themes using content analysis.Results: A total of 25 physicians participated in the six focus groups, which yielded 12 hours of discussion. Providers identified multiple barriers to timely and accurate diagnosis, including organizational culture, information availability, and communication factors.Conclusions: Multiple themes relating to each of the participants in the diagnostic process—health system, provider, and patient—emerged. Concerns about health system structure and providers' interactions with one another and with patients far exceeded discussion of the cognitive factors that might affect the diagnostic process. The results suggest that, at least in physicians' views, improving the diagnostic process requires attention to the organization of the health system in addition to the cognitive aspects of diagnosis.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 10/2014; 40(10).
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    Journal of alternative and complementary medicine (New York, N.Y.) 05/2014; 20(5):A126. · 1.69 Impact Factor
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    ABSTRACT: Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events. To elicit patient and provider perspectives on ambulatory ADEs and apply root cause analysis methodology to identify cross-cutting themes among these events. Emergency department clinical pharmacists screened, identified, and enrolled a convenience sample of adult patients 18 years or older who presented to a single, urban, academic ED with symptoms or diagnoses consistent with suspected ADEs. Semistructured phone interviews were conducted with the patients and their providers. We conducted a qualitative analysis. We applied a prespecified version of the injury prevention framework (deductive coding), identifying themes relating to the agent (drug), host (patient), and environment (social and health systems). These themes were used to construct a root cause analysis for each ADE. From 18 interviews overall, we identified the following themes within the injury prevention framework. Agent factors included high-risk drugs, narrow therapeutic indices, and uncommon severe effects. Host factors included patient capacity or understanding of how to use medications, awareness of side effects, mistrust of the medical system, patients with multiple comorbidities, difficult risk-benefit assessments, and high health-care users. Environmental factors included lack of social support, and health systems issues included access to care, encompassing medication availability, access to specialists, and a lack of continuity and communication among prescribing physicians. Root cause analysis revealed multiple underlying factors relating to agent, host, and environment for each event. Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.
    Journal of Patient Safety 02/2014;
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    ABSTRACT: Improved drug labelling for chronic pill-form medications has been shown to promote patient comprehension, adherence and safety. We extended health literacy principles and included patients' perspectives to improve instructions for: (1) non-pill form, (2) short term, (3) 'as needed,' (4) tapered and (5) escalating dose medications. Participants were recruited via convenience sampling from primary care clinics in Chicago, Illinois and San Francisco, California, USA. 40 adult, English-speaking participants who reported taking at least one prescription drug in the past 12 months were enrolled in the study. Participant opinions, preferences and comprehension of standard and improved medication instructions were assessed during four iterative waves of discussion groups. Brief interviews preceding the discussion groups measured individuals' literacy skills, sociodemographic and health characteristics. On average, participants were 46 years old, took four medications and reported two chronic health conditions. Patients varied sociodemographically; 40% were men and 33% had limited literacy skills. Patients agreed on the need for simpler terminology and specificity in instructions. Discussions addressed optimal ways of presenting numeric information, indication and duration of use information to promote comprehension and safe medication use. Consensus was reached on how to improve most of the instructions. Through this patient-centred approach, we developed a set of health literacy-informed instructions for more challenging medications. Findings can inform current drug labelling initiatives and promote safe and appropriate medication use.
    BMJ Open 01/2014; 4(1):e003699. · 1.58 Impact Factor
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    ABSTRACT: Background. Social risk factors for hypoglycemia are not well understood. Methods. Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005-2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors. Results. 14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs. high-income (16% vs. 8.8) and low-education vs. high-education (11.9% vs. 8.9%) groups. In multivariable analysis, incomes of less than $15,000 (OR 1.51 95%CI 1.19-1.91), $15,000-$24,999 (OR 1.57 95%CI 1.27-1.94), and high school or less education (OR 1.42, 95% CI 1.24-1.63) were associated with increased hypoglycemia, similar to insulin use (OR 1.44 95%CI 1.19-1.74). Conclusions. Low income and educational attainment are important risk factors for hypoglycemia.
    Journal of Health Care for the Poor and Underserved 01/2014; 25(2):478-90. · 1.10 Impact Factor
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    ABSTRACT: Online patient portals are being widely implemented, but their impact on health behaviors are not well-studied. To determine whether statin adherence improved after initiating use of the portal refill function. Observational cohort study within an integrated health care delivery system. Diabetic patients on statins who had registered for online portal access by 2010. A total of 8705 subjects initiated the online refill function use within the study window, including "exclusive" and "occasional" users (ie, requesting all vs. some refills online, respectively). Using risk-set sampling, we temporally matched 9055 reference group patients who never used online refills. We calculated statin adherence before and after refill function initiation, assessed as percent time without medications (nonadherence defined as a gap of >20%). Secondary outcome was dyslipidemia [low-density lipoprotein (LDL)≥100]. Difference-in-differences regression models estimated pre-post changes in nonadherence and dyslipidemia, comparing refill function users to the reference group and adjusting for age, sex, race/ethnicity, medications, frequency of portal use, and outpatient visits. In unadjusted examinations, nonadherence decreased only among patients initiating occasional or exclusive use of the refill function (26%-24% and 22%-15%, respectively). In adjusted models, nonadherence declined by an absolute 6% (95% confidence interval, 4%-7%) among exclusive users, without significant changes among occasional users. Similar LDL decreases were also seen among exclusive users. Compared with portal users who did not refill medications online, adherence to statin medications and LDL levels improved among diabetic patients who initiated and exclusively used the patient portal for refills, suggesting that wider adoption of online refills may improve adherence.
    Medical care 12/2013; · 3.24 Impact Factor
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    ABSTRACT: Health reform requires safety net settings to transform care delivery, but how they will innovate in order to achieve this transformation is unknown. Two series of key informant interviews (N = 28) were conducted in 2012 with leadership from both California's public hospital systems and community health centers. Interviews focused on how innovation was conceptualized and solicited examples of successful innovations. In contrast to disruptive innovation, interviewees often defined innovation as improving implementation, making incremental changes, and promoting integration. Many leaders gave examples of existing innovative practices to meeting their diverse patient needs, such as patient-centered approaches. Participants expressed challenges to adapting quickly, but a desire to partner together. Safety net systems have already begun implementing innovative practices supporting their key priority areas. However, more support is needed, specifically to accelerate the change needed to succeed under health reform.
    American Journal of Medical Quality 10/2013; · 1.47 Impact Factor
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    ABSTRACT: Patient-provider relationships influence diabetes care; less is known about their impact on online patient portal use. Diabetes patients rated provider communication and trust. In this study, we linked responses to electronic medical record data on being a registered portal user and using secure messaging (SM). We specified regression models to evaluate main effects on portal use, and subgroup analyses by race/ethnicity and age. 52% of subjects were registered users; among those, 36% used SM. Those reporting greater trust were more likely to be registered users (relative risk (RR)=1.14) or SM users (RR=1.29). In subgroup analyses, increased trust was associated with being a registered user among white, Latino, and older patients, as well as SM use among white patients. Better communication ratings were also related to being a registered user among older patients. Since increased trust and communication were associated with portal use within subgroups, this suggests that patient-provider relationships encourage portal engagement.
    Journal of the American Medical Informatics Association 05/2013; · 3.57 Impact Factor
  • JAMA Internal Medicine 03/2013; · 10.58 Impact Factor
  • Courtney R Lyles, Urmimala Sarkar
    BMJ quality & safety 03/2013; · 2.39 Impact Factor
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    ABSTRACT: Diabetes complications account for significant worldwide morbidity and mortality. Improving glycemic control decreases microvascular complications, particularly among patients with the worst control. Current performance measures fail to prioritize such individuals. The categorization of glycemic control within a safety-net clinic population was compared using a common performance measure against one derived from a metric accounting for change in glycated hemoglobin (A1c) over time. Retrospective cohort analysis of all patients in a safety-net primary care clinic population quality registry with confirmed diabetes mellitus who had at least two A1c values between 2007 through 2011. Patients were stratified into five groups' on the basis of maximum and earliest A1c level (< 7%, 7% to < 8%, 8% to < 9%, 9% to < 10%, and > 10%). The change in Alc was assessed over time and compared with standard healthcare effectiveness data and information set (HEDIS) performance measures. Some 1122 patients were included in the analysis, with mean A1c of 7.9%. There was a modest annual decrease in the average A1c, and > 19% of patients improved by 1% or more during each of the previous three years. For patients who had maximum A1c values > or = 10%, there was a significantly greater reduction in A1c (p < .01), which was not reflected in the standard performance measure. It is feasible for safety-net clinics to analyze their patients with diabetes by level of disease control on the basis of change in A1c over time. Patients with the worst glycemic control tend to have the greatest improvement but are often overlooked by conventional performance measures. Improved performance measures should focus on longitudinal diabetes control and emphasize reducing risk of complications among patients at highest risk.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 03/2013; 39(3):109-13.
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    ABSTRACT: OBJECTIVE: To determine whether diabetes clinical standards consider increased hypoglycemia risk in vulnerable patients. DATA SOURCES: MEDLINE, the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, and supplemental sources. STUDY DESIGN: Systematic review of clinical standards (guidelines, quality metrics, or pay-for-performance programs) for glycemic control in adult diabetes patients. The primary outcome was discussion of increased risk for hypoglycemia in vulnerable populations. DATA COLLECTION/EXTRACTION METHODS: Manuscripts identified were abstracted by two independent reviewers using prespecified inclusion/exclusion criteria and a standardized abstraction form. PRINCIPAL FINDINGS: We screened 1,166 titles, and reviewed 220 manuscripts in full text. Forty-four guidelines, 17 quality metrics, and 8 pay-for-performance programs were included. Five (11 percent) guidelines and no quality metrics or pay-for-performance programs met the primary outcome. CONCLUSIONS: Clinical standards do not substantively incorporate evidence about increased risk for hypoglycemia in vulnerable populations.
    Health Services Research 02/2013; · 2.29 Impact Factor
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    ABSTRACT: BACKGROUND: Electronic and internet-based tools for patient-provider communication are becoming the standard of care, but disparities exist in their adoption among patients. The reasons for these disparities are unclear, and few studies have looked at the potential communication technologies have to benefit vulnerable patient populations. OBJECTIVE: To characterize access to, interest in, and attitudes toward internet-based communication in an ethnically, economically, and linguistically diverse group of patients from a large urban safety net clinic network. DESIGN: Observational, cross-sectional study PARTICIPANTS: Adult patients (≥ 18 years) in six resource-limited community clinics in the San Francisco Department of Public Health (SFDPH) MAIN MEASURES: Current email use, interest in communicating electronically with health care professionals, barriers to and facilitators of electronic health-related communication, and demographic data-all self-reported via survey. KEY RESULTS: Sixty percent of patients used email, 71 % were interested in using electronic communication with health care providers, and 19 % reported currently using email informally with these providers for health care. Those already using any email were more likely to express interest in using it for health matters. Most patients agreed electronic communication would improve clinic efficiency and overall communication with clinicians. CONCLUSIONS: A significant majority of safety net patients currently use email, text messaging, and the internet, and they expressed an interest in using these tools for electronic communication with their medical providers. This interest is currently unmet within safety net clinics that do not offer a patient portal or secure messaging. Tools such as email encounters and electronic patient portals should be implemented and supported to a greater extent in resource-poor settings, but this will require tailoring these tools to patients' language, literacy level, and experience with communication technology.
    Journal of General Internal Medicine 02/2013; · 3.28 Impact Factor
  • Seth Cohen, Urmimala Sarkar
    Academic medicine: journal of the Association of American Medical Colleges 01/2013; 88(1):66. · 2.34 Impact Factor
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    ABSTRACT: Interactive health information technology (HIT) can support the complex self-management tasks for diabetes. However, less is known about between-visit interactions and patient safety among chronic illness patients treated in the outpatient setting. We classified 13 categories for safety events and potential safety events within a larger trial evaluating a multilingual automated telephone self-management support system for diabetes using interactive voice response. Participants could trigger safety concerns by reporting hyperglycemia or hypoglycemia, inability to obtain medications, medication nonadherence and side effects, and needing appointments and/or supplies. We then examined these triggers across patient demographic and health characteristics to determine which patients were most likely to experience safety events. Overall, there were 360 safety triggers that occurred among 155 participants, which represented 53% of individuals and 7.6% of all automated calls over the 27-week intervention. The most common triggers were for pain or medication side effects (22%) and not checking blood sugars (13%). In adjusted models, race/ethnicity and language were related to safety triggers; Spanish-speaking participants were significantly (p = .02) more likely than English-speaking participants to experience a safety trigger, and black participants were marginally more likely (p = .09) than white participants to experience a safety trigger. About half of patients enrolled in a self-management technology intervention triggered at least one potential safety event over the course of the trial, and this was more frequent among some patients. Systems implementing HIT strategies to improve self-care and remote monitoring should consider specific program design elements to address these potential safety events.
    Journal of diabetes science and technology 01/2013; 7(3):596-601.
  • Alissa Detz, Andrea López, Urmimala Sarkar
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    ABSTRACT: Continuity of patient care is one of the cornerstones of primary care. To examine publicly available, Internet-based reviews of adult primary care physicians, specifically written by patients who report long-term relationships with their physicians. This substudy was nested within a larger qualitative content analysis of online physician ratings. We focused on reviews reflecting an established patient-physician relationship, that is, those seeing their physicians for at least 1 year. Of the 712 Internet reviews of primary care physicians, 93 reviews (13.1%) were from patients that self-identified as having a long-term relationship with their physician, 11 reviews (1.5%) commented on a first-time visit to a physician, and the remainder of reviews (85.4%) did not specify the amount of time with their physician. Analysis revealed six overarching domains: (1) personality traits or descriptors of the physician, (2) technical competence, (3) communication, (4) access to physician, (5) office staff/environment, and (6) coordination of care. Our analysis shows that patients who have been with their physician for at least 1 year write positive reviews on public websites and focus on physician attributes.
    Journal of Medical Internet Research 01/2013; 15(7):e131. · 3.77 Impact Factor
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    ABSTRACT: 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 patientreported 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.
    The American journal of managed care 12/2012; 18(12):807-15. · 2.12 Impact Factor
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    ABSTRACT: Twitter.com is a "micro-blogging" website. Although Twitter use is growing rapidly, little is known about health behavior discussions on this site, even though a majority of messages are publicly available. We retrieved publicly available Twitter messages during a 5-week period in early 2012, searching separately for the terms "Pap smear" and "mammogram." We used content analysis to code each 140-character message, generating a separate coding framework for each cancer screening term and calculating the frequencies of comments. Using the brief account description, we also coded the author as individual, organization, or news media outlet. There were 203 Pap smear and 271 mammogram messages coded, over three fourths of which were from individual accounts. Overall, 22 % of Pap smear messages and 25 % of mammogram messages discussed personal experiences, including attending appointments, negative sentiment about the procedure, and results. Other messages from both individuals and organizations (8 % Pap smear, 18 % mammogram) promoted screening. About one quarter of the messages expressed personal experiences with cancer screening. This demonstrates that Twitter can be a rich source of information and could be used to design new health-related interventions.
    Journal of Cancer Education 11/2012; · 0.88 Impact Factor
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    ABSTRACT: BACKGROUND: Limited health literacy is associated with poor outcomes in many chronic diseases, but little is known about health literacy in chronic obstructive pulmonary disease (COPD). OBJECTIVE: To examine the associations between health literacy and both outcomes and health status in COPD. PARTICIPANTS, DESIGN AND MAIN MEASURES: Structured interviews were administered to 277 subjects with self-report of physician-diagnosed COPD, recruited through US random-digit telephone dialing. Health literacy was measured with a validated three-item battery. Multivariable linear regression, controlling for sociodemographics including income and education, determined the cross-sectional associations between health literacy and COPD-related health status: COPD Severity Score, COPD Helplessness Index, and Airways Questionnaire-20R [measuring respiratory-specific health-related quality of life (HRQoL)]. Multivariable logistic regression estimated associations between health literacy and COPD-related hospitalizations and emergency department (ED) visits. KEY RESULTS: Taking socioeconomic status into account, poorer health literacy (lowest tertile compared to highest tertile) was associated with: worse COPD severity (+2.3 points; 95 % CI 0.3-4.4); greater COPD helplessness (+3.7 points; 95 % CI 1.6-5.8); and worse respiratory-specific HRQoL (+3.5 points; 95 % CI 1.8-4.9). Poorer health literacy, also controlling for the same covariates, was associated with higher likelihood of COPD-related hospitalizations (OR = 6.6; 95 % CI 1.3-33) and COPD-related ED visits (OR = 4.7; 95 % CI 1.5-15). Analyses for trend across health literacy tertiles were statistically significant (p < 0.05) for all above outcomes. CONCLUSIONS: Independent of socioeconomic status, poor health literacy is associated with greater COPD severity, greater COPD helplessness, worse respiratory-specific HRQoL, and higher odds of COPD-related emergency health-care utilization. These results underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes.
    Journal of General Internal Medicine 08/2012; · 3.28 Impact Factor

Publication Stats

528 Citations
171.05 Total Impact Points

Institutions

  • 2013
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
  • 2010–2012
    • San Francisco VA Medical Center
      San Francisco, California, United States
    • CSU Mentor
      Long Beach, California, United States
  • 2006–2012
    • University of California, San Francisco
      • • Division of General Internal Medicine
      • • Division of Hospital Medicine
      San Francisco, CA, United States
  • 2011
    • Kaiser Permanente
      Oakland, California, United States