Minority/Medicaid Status Associated With Lower PRO Utilization in Oncology

Patients with solid tumors or hematologic malignancies who identified as a racial or ethnic minority or have a lower socioeconomic status were associated with lower portal engagement and lower completion rates for patient-reported outcome (PRO) measures prior to appointments, according to findings from a secondary analysis of the Northwestern University IMproving the Management of symPtoms during and following Cancer Treatment (NU IMPACT) published in the Journal of Clinical Oncology Clinical Cancer Informatics.¹

In the trial, 3457 patients were enrolled and underwent regular symptom monitoring via PROs delivered through patient portals within electronic health records (EHRs). Patients on the trial had a median number of 3 oncology visits (IQR, 0-68), and 91% were considered health literate, being quite a bit or extremely comfortable filling out medical forms independently.

Findings revealed that 97.5% of patients in the study viewed their laboratory results at least once, for a median of 23 days out of the year of a year-long study period (IQR, 10-46). Additionally, a clinical messaging feature was used at least once by 95.5% of patients, for a median of 11 days (IQR, 5-21). Utilization of physician notes occurred in 71.2% of patients, for a median of 2 days viewed (IQR, 1-4); the average rate of PRO completion was 46.6%.

Notably, the use of any portal feature was positively correlated with the use of any other portal feature (P = 0.32-0.68). Additionally, the number of appointments was positively correlated with any portal feature (P = 0.37-0.62).

Regarding the completion of PROs, patients with increasing levels of education were associated with higher rates of engagement compared with high school or less or some college; the incidence rate ratios among college graduates and those with graduate or advanced degrees vs those with high school attainment or less was 1.21 (95% CI, 1.08-1.35; P = .001) and 1.33 (95% CI, 1.19-1.49), respectively. Additionally, female patients had a higher completion rate than male patients, with an IRR of 1.06 (95% CI, 1.00-1.12; P = .043).

Compared with White patients, Black and Hispanic/Latino patients had lower PRO completion rates, with respective IRRs of 0.81 (95% CI, 0.70-0.93; P = .003) and 0.70 (95% CI, 0.59-0.83; P <.001). Patients with Medicaid also had a lower rate of PRO completion vs those who were privately insured, with an IRR of 0.78 (95% CI, 0.65-0.93; P = .006).

“Our study finds that disparities persist in patient portal engagement among patients with cancer, with lower engagement among racial and ethnic minorities and patients with lower socioeconomic status,” Kyle M. Nolla, PhD, MS, assistant professor of Psychology at Morgan State University, wrote in the publication with study co-investigators.¹ “Future research should focus on understanding the underlying causes of these differences and developing strategies to address them, ensuring that the benefits of patient portals and regular PRO reporting are accessible to all patients with cancer.”

The NU IMACT study is a modified stepped-wedge trial that used system-level implementation evaluation to draw comparisons between the EHR-integrated cancer symptom monitoring and management system (NMPRO) and the NU IMPACT intervention. The 2-step study initially began as a clinic-level pragmatic roll-out implementation trial, which aimed to evaluate approximately 600 patients before and after implementation of the intervention.² It also included a patient-level randomized controlled trial embedded in the post-implementation phase to compare PROs with usual care vs with an enhanced care approach involving more active engagement of patients.

Patients included in the study were English- or Spanish-speaking adults diagnosed with a solid tumor or hematologic malignancy within 10 years of enrollment. Those included also received treatment or survivorship care across 30 sites between April 2020 and April 2023. Patients must have completed baseline surveys, had an active patient portal account, and had a cancer diagnosis identified by the EHR to be eligible for inclusion in the analysis.

Among all participants in the survey, 65% were female, 54% were between 40 and 65 years old, and most were college graduates, with 35% being college graduates and 34% having attained a graduate/advanced degree. Most patients were employed (45%) or retired (38%), White (85%), and non-Hispanic (85%). Additionally, 54% had private insurance, 40% had Medicare or Medicare Advantage, and 3.2% had Medicaid.

The frequency of grade 3/4 PRO-Common Terminology Criteria for Adverse Events (CTCAE) was 21%, with 15% of patients reporting 1 event and 4.2% of patients reporting 2 events. The most common cancer types included breast (30%), lymphoma (12%), gastrointestinal not including colorectal malignancies (9.0%), and leukemia (8.7%).

References

1. Nolla KM, Kuharic M, Lancki N, et al. Patient portal engagement in oncology: results from the NU IMPACT study in a large health care system. JCO Clin Cancer Inform. 2025;9:e2500178. doi:10.1200/CCI-25-00178
2. NU IMPACT study: recruiting and consenting through the EDW in REDCap. Northwestern Medicine Feinberg School of Medicine. October 19, 2021. Accessed December 24, 2025. https://tinyurl.com/3uerdzj8