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Lussier ME, Desai RJ, Wright EA, Gionfriddo MR. Impact of cost on prescribing diabetes medications for older adults with type 2 diabetes in the outpatient setting. Res Social Adm Pharm 2024; 20:755-759. [PMID: 38697890 DOI: 10.1016/j.sapharm.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Newer diabetes medications have cardiorenal benefits beyond blood sugar lowering that make them a preferred treatment option in many patients. Despite this, studies have shown that prescribing of these medications remains suboptimal with medication costs being hypothesized as a reason for underutilization. OBJECTIVE To understand clinicians' decision-making processes for prescribing diabetes medications in older adults, focusing on higher cost medications. METHODS Observations of patient encounters and semi-structured interviews were conducted with clinicians from primary care, endocrinology, and geriatrics to elucidate themes into diabetes medication prescribing. A qualitative descriptive approach was used to analyze the data from interviews using an inductive coding scheme with themes derived from the data. RESULTS Twenty-one interviews were conducted. Five themes were identified: 1) out-of-pocket costs drive prescribing decisions 2) out-of-pocket costs can be variable due to changing insurance plans or changing coverage 3) clinicians have difficulty with determining patient-specific out-of-pocket costs 4) clinicians manage the tradeoffs existing between cost, efficacy, and safety and 5) clinicians can use cost-modifying strategies such as patient assistance. CONCLUSION Addressing the challenges that medication costs pose to prescribing evidence-based medications for type 2 diabetes is necessary to optimize diabetes care for older adults.
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Affiliation(s)
- Mia E Lussier
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA; Binghamton University, School of Pharmacy and Pharmaceutical Sciences, PO Box 6000, Binghamton, NY, 13902-6000, USA.
| | - Ravi J Desai
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA
| | - Eric A Wright
- Geisinger, Center for Pharmacy Innovation and Outcomes, 100 North Academy Avenue, Danville, PA, USA
| | - Michael R Gionfriddo
- Duquesne University, Division of Pharmaceutical, Administrative, and Social Sciences, 600 Forbes Avenue, Pittsburgh, PA, 15282, USA
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Kennedy KL, Kong WY, Heisler-MacKinnon J, Medlin R, Loughlin CE, Lawler CN, Hernandez ML, Galbraith AA, Gilkey MB. Using Cost Conversations to Address Financial Toxicity in Pediatric Asthma Care: Findings From a Survey of Caregivers. J Pediatr Health Care 2024; 38:374-381. [PMID: 38043046 DOI: 10.1016/j.pedhc.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/05/2023] [Accepted: 10/26/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION Asthma care teams are well-positioned to help caregivers address financial toxicity in pediatric asthma care, although discussing cost can be challenging. We sought to characterize cost conversations in pediatric asthma specialty care. METHOD We surveyed 45 caregivers of children aged 4-17 with asthma. Eligible caregivers reported costs concerns and had accompanied their child to a multisite asthma specialty practice in North Carolina. RESULTS About one-third of caregivers reported a cost conversation (36%). Cost conversations were less common among caregivers whose child had public versus private health insurance (16% vs. 56%), who attended a telehealth versus in-person visit (6% vs. 52%), or who did not versus did want a conversation (19% vs. 77%, all p < .05). Common cost conversation topics were medications and equipment like spacers. DISCUSSION Our findings suggest cost conversations may be relatively uncommon in pediatric asthma care, particularly for publicly insured patients and telehealth visits.
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Fitzpatrick V, Erwin K, Rivelli A, Shields M, Delfinado L, Cabiya M, Wennerberg K. The potential impact of introducing a cost tool to facilitate cost-of-care conversations in routine OB care: Lessons from the CONTINUE pilot study. PEC INNOVATION 2023; 2:100136. [PMID: 37214536 PMCID: PMC10194338 DOI: 10.1016/j.pecinn.2023.100136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 05/24/2023]
Abstract
Objective The objective of the CONTINUE study is to gather preliminary data on the potential impact of implementing a "Cost Tool" in routine obstetrics (OB) care. It is hypothesized that by providing prenatal patients with an ability to forecast their care plan, they would be better able to anticipate and plan for the costs associated with their prenatal care. Methods Pilot data from interviews and surveys were collected from 71 prenatal patients across three clinics throughout Chicago, IL. Results As compared to privately insured prenatal patients, prenatal patients with public insurance reported the most benefit in Cost Tool use. Specifically, that the Cost Tool helped to navigate insurance more effectively (OR 4.49, p=0.0254), see the "Big Picture" and link it to the family budget (OR 4.25, p=0.0099), and make the financial tradeoffs needed to get through pregnancy (OR 5.50, p=0.0305). Conclusion The CONTINUE study provides preliminary signals of the Cost Tool's potential to help publicly insured prenatal patients better navigate the costs associated with their care plan. Innovations The CONTINUE study contributes valuable preliminary data about the utility of a cost tool in routine OB care, especially as it may benefit low-income prenatal patients navigate prenatal care better.
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Affiliation(s)
- Veronica Fitzpatrick
- Advocate Aurora Research Institute, Downers Grove, IL, USA
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Kim Erwin
- Illinois Institute of Technology Institute of Design, Chicago, IL, USA
| | - Anne Rivelli
- Advocate Aurora Research Institute, Downers Grove, IL, USA
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Maureen Shields
- Advocate Aurora Research Institute, Downers Grove, IL, USA
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Leah Delfinado
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
| | - Marie Cabiya
- Advocate Aurora Health; Downers Grove, IL, Milwaukee, WI, USA
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Garcia-Bautista A, Kamath C, Ayala N, Behnken E, Giblon RE, Gravholt D, Hernández-Leal MJ, Hidalgo J, Leon Garcia M, Golembiewski EH, Maraboto A, Sivly A, Brito JP. Financial Toxicity in the Clinical Encounter: A Paired Survey of Patient and Clinician Perceptions. Mayo Clin Proc Innov Qual Outcomes 2023; 7:248-255. [PMID: 37359420 PMCID: PMC10285501 DOI: 10.1016/j.mayocpiqo.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Objective To compare the agreement between patient and clinician perceptions of care-related financial issues. Patients and Methods We surveyed patient-clinician dyads immediately after an outpatient medical encounter between September 2019 and May 2021. They were asked to separately rate (1-10) patient's level of difficulty in paying medical bills and the importance of discussing cost issues with that patient during clinical encounters. We calculated agreement between patient-clinician ratings using the intraclass correlation coefficient and used random effects regression models to identify patient predictors of paired score differences in difficulty and importance of ratings. Results 58 pairs of patients (n=58) and clinicians (n=40) completed the survey. Patient-clinician agreement was poor for both measures, but higher for difficulty in paying medical bills (intraclass correlation coefficient=0.375; 95% CI, 0.13-0.57) than for the importance of discussing cost (-0.051; 95% CI, -0.31 to 0.21). Agreement on difficulty in paying medical bills was not lower in encounters with conversations about the cost of care. In adjusted models, poor patient-clinician agreement on difficulty in paying medical bills was associated with lower patient socioeconomic status and education level, whereas poor agreement on patient-perceived importance of discussing cost was significant for patients who were White, married, reported 1 or more long-term conditions, and had higher education and income levels. Conclusion Even in encounters where cost conversations occurred, there was poor patient-clinician agreement on ratings of the patient's difficulty in paying medical bills and perceived importance of discussing cost issues. Clinicians need more training and support in detecting the level of financial burden and tailoring cost conversations to the needs of individual patients.
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Affiliation(s)
- Andrea Garcia-Bautista
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Celia Kamath
- Robert D and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Nicolas Ayala
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Emma Behnken
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Rachel E Giblon
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Derek Gravholt
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - María José Hernández-Leal
- Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Pamplona, Spain
- Medical Sciences, Universidad de La Frontera, Temuco, Chile
- Millenium Nucleus of Sociomedicine (Sociomed), Santiago, Chile
| | - Jessica Hidalgo
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Montserrat Leon Garcia
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
- Iberoamerican Cocharane Center, Biomedical Research Institute Sant Pau, Barcelona, Spain
| | | | - Andrea Maraboto
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Angela Sivly
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Juan P Brito
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
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Rezaei S, Peikanpour M, Zarei L, Mohammadnezhad G, Salamzadeh J. An adapted model of cost-related medication nonadherence among older adult patients with chronic diseases: an Iranian qualitative study. BMC Geriatr 2023; 23:208. [PMID: 37003968 PMCID: PMC10067279 DOI: 10.1186/s12877-023-03907-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/20/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Following the rapid aging of population, some concerns have emerged regarding increasing demand for health care services and the consequent increase in health costs. Besides, older adult patients with chronic disease are more prone to show cost-related medication non-adherence (CRN) to cope with their medication costs. The objective of this qualitative study was to develop an adopted conceptual framework on the contextual determinants that affect the CRN in older adult patients with chronic diseases. METHODS Problem-centered, semi-structured, in-depth, and face-to-face interviews, were conducted with healthcare informants in Iran, from Sep. 2021 to Feb. 2022. Collected data were analyzed using deductive and inductive analytic approaches and content analysis methodology was used to develop the model. This study applies to the COREQ checklist. RESULTS Fifteen informants, including 8 (60%) males, with mean ± SD age of 44.4 ± 9.7 years, entered into the study. Based on the data analysis performed on the information obtained from the interview with 3 subgroups of geriatricians, health policymakers, and pharmacists, six major themes identified as determinants: 1) socio-economic factors, 2) health system-related factors, 3) healthcare provider-related factors, 4) medication-related factors, 5) disease-related factors, and 6) patient-related factors. There were also 23 minor themes which were matched with the aforementioned six major themes. CONCLUSION The final framework obtained in this qualitative study depicts CRN as an issue that is highly likely affected by six main determinants among older patients with chronic disease. Our findings emphasize that policymakers would focus on certain major themes and allocate resources to programs to improve medication therapy management in older adult patients.
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Affiliation(s)
- Soheila Rezaei
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Peikanpour
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Zarei
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ghader Mohammadnezhad
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jamshid Salamzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences Sciences, Niayesh Highway, Valiasr Ave, P.O. Box 14155-6153, Tehran, Iran.
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Everson J, Henderson SC, Cheng A, Senft N, Whitmore C, Dusetzina SB. Demand for and Occurrence of Medication Cost Conversations: A Narrative Review. Med Care Res Rev 2023; 80:16-29. [PMID: 35808853 DOI: 10.1177/10775587221108042] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
High medication prices can create a financial burden for patients and reduce medication initiation. To improve decision making, public policy is supporting development of tools to provide real-time prescription drug prices. We reviewed the literature on medication cost conversations to characterize the context in which these tools may be used. Our review included 42 articles: a median of 84% of patients across four clinical specialties reported a desire for cost conversations (n = 7 articles) but only 23% reported having held a cost conversation across six specialties (n = 16 articles). Non-White and older patients were less likely to report having held a cost conversation than White and younger patients in 9 of 13 and 5 of 9 articles, respectively, examining these associations. Our review indicates that tools providing price information may not result in improved decision making without complementary interventions that increase the frequency of cost conversations with a focus on protected groups.
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Affiliation(s)
- Jordan Everson
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Audrey Cheng
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | | | - Stacie B Dusetzina
- Vanderbilt University School of Medicine, Nashville, TN, USA.,Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
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7
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Espinoza Suarez NR, LaVecchia CM, Morrow AS, Fischer KM, Kamath C, Boehmer KR, Brito JP. ABLE to support patient financial capacity: A qualitative analysis of cost conversations in clinical encounters. PATIENT EDUCATION AND COUNSELING 2022; 105:3249-3258. [PMID: 35918230 DOI: 10.1016/j.pec.2022.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To explore how costs of care are discussed in real clinical encounters and what humanistic elements support them. METHODS A qualitative thematic analysis of 41 purposively selected transcripts of video-recorded clinical encounters from trials run between 2007 and 2015. Videos were obtained from a corpus of 220 randomly selected videos from 8 practice-based randomized trials and 1 pre-post prospective study comparing care with and without shared decision making (SDM) tools. RESULTS Our qualitative analysis identified two major themes: the first, Space Needed for Cost Conversations, describes patients' needs regarding their financial capacity. The second, Caring Responses, describes humanistic elements that patients and clinicians can bring to clinical encounters to include good quality cost conversations. CONCLUSION Our findings suggest that strengthening patient-clinician human connections, focusing on imbalances between patient resources and burdens, and providing space to allow potentially unexpected cost discussions to emerge may best support high quality cost conversations and tailored care plans. PRACTICE IMPLICATIONS We recommend clinicians consider 4 aspects of communication, represented by the mnemonic ABLE: Ask questions, Be kind and acknowledge emotions, Listen for indirect signals and (discuss with) Every patient. Future research should evaluate the practicality of these recommendations, along with system-level improvements to support implementation of our recommendations.
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Affiliation(s)
- Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Centre for Sustainable Health Research, Laval University, Quebec, QC, Canada
| | | | - Allison S Morrow
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Milken Institute School of Public Health, The George Washington University, Washington DC, USA
| | - Karen M Fischer
- Division of Biomedical Statistics and Informatics, Mayo Clinic, MN, USA
| | - Celia Kamath
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, MN, USA.
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8
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Gilkey MB, Kong WY, Kennedy KL, Heisler-MacKinnon J, Faugno E, Gwinn B, Wu AC, Loughlin CE, Galbraith AA. Leveraging Telemedicine to Reduce the Financial Burden of Asthma Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2536-2542. [PMID: 35644331 DOI: 10.1016/j.jaip.2022.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/04/2022] [Accepted: 05/17/2022] [Indexed: 06/15/2023]
Abstract
One of the most compelling arguments for telemedicine is its potential to increase health care access by making care more affordable for patients and families, including those affected by asthma. This goal is critically important in the United States, where the high cost of asthma care is associated with nonadherence to preventive care regimens and suboptimal health outcomes. In this clinical commentary review, we draw from the literature and our own research to identify opportunities for and challenges to leveraging telemedicine to reduce the financial burden of asthma care. Our interviews with 42 families affected by asthma during the COVID-19 pandemic suggest that under favorable circumstances, telemedicine can meaningfully reduce costs, including those related to transportation and missed work, while offering high-quality care. However, families also identified ways in which telemedicine can increase costs. For example, some reported reduced access to support services and material resources such as medication samples, which they relied on to manage costs. In this way, our findings underscore the need for careful care coordination and communication in telemedicine. We conclude by discussing the 4Rs, a structured communication approach designed to support cost conversations, increase care coordination, and help families reduce asthma care cost burden.
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Affiliation(s)
- Melissa B Gilkey
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC.
| | - Wei Yi Kong
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC
| | - Kathryn L Kennedy
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC
| | | | - Elena Faugno
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
| | - Barbara Gwinn
- NC Children's Allergy and Asthma Center, UNC Health, Chapel Hill, NC
| | - Ann Chen Wu
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
| | - Ceila E Loughlin
- NC Children's Allergy and Asthma Center, UNC Health, Chapel Hill, NC; Department of Pediatrics, Division of Pulmonology, University of North Carolina, Chapel Hill, NC
| | - Alison A Galbraith
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Mass
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Bassett HK, Beck J, Coller RJ, Flaherty B, Tiedt KA, Hummel K, Tchou MJ, Kapphahn K, Walker L, Schroeder AR. Parent Preferences for Transparency of Their Child's Hospitalization Costs. JAMA Netw Open 2021; 4:e2126083. [PMID: 34546372 PMCID: PMC8456391 DOI: 10.1001/jamanetworkopen.2021.26083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/16/2021] [Indexed: 01/20/2023] Open
Abstract
Importance Health care in the US is often expensive for families; however, there is little transparency in the cost of medical services. The extent to which parents want cost transparency in their children's care is not well characterized. Objective To explore the preferences and experiences of parents of hospitalized children regarding the discussion and consideration of health care costs in the inpatient care of their children. Design, Setting, and Participants This cross-sectional multicenter survey study included 6 geographically diverse university-affiliated US children's hospitals from November 3, 2017, to November 8, 2018. Participants included a convenience sample of English- and Spanish-speaking parents of hospitalized children nearing hospital discharge. Data were analyzed from January 1, 2020, to June 25, 2021. Main Outcomes and Measures Parents' preferences and experiences regarding transparency of their child's health care costs. Multivariable linear regression examined associations between clinical and sociodemographic variables with parents' preferences for knowing, discussing, and considering costs in the clinical setting. Factors included family financial difficulties, child's level of chronic disease, insurance payer, deductible, family poverty level, race, ethnicity, parental educational level, and study site. Results Of 644 invited participants, 526 (82%) were enrolled (290 [55%] male), of whom 362 (69%) were White individuals, 400 (76%) were non-Hispanic/Latino individuals, and 274 (52%) had children with private insurance. Overall, 397 families (75%) wanted to discuss their child's medical costs, but only 36 (7%) reported having a cost conversation. If cost discussions were to occur, 294 families (56%) would prefer to speak to a financial counselor. Ninety-eight families (19%) worried discussing costs would hurt the quality of their child's care. Families with a medical financial burden unrelated to their hospitalized child had higher mean agreement that their child's physician should consider the family's costs in medical decision-making than families without a medical financial burden (effect size, 0.55 [95% CI, 0.18-0.92]). No variables were consistently associated with cost transparency preferences. Conclusions and Relevance Most parents want to discuss their child's costs during an acute hospitalization. Discussions of health care costs may be an important, relatively unexplored component of family-centered care. However, these discussions rarely occur, indicating a tremendous opportunity to engage and support families in this issue.
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Affiliation(s)
- Hannah K. Bassett
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jimmy Beck
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Ryan J. Coller
- Deparment of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Brian Flaherty
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City
| | - Kristin A. Tiedt
- Deparment of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Kevin Hummel
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City
- currently affiliated with Division of Cardiology, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael J. Tchou
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
- currently affiliated with Section of Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado Denver, Aurora
| | | | - Lauren Walker
- Section of Hospital Medicine, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Alan R. Schroeder
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Espinoza Suarez NR, LaVecchia CM, Fischer KM, Kamath CC, Brito JP. Impact of Cost Conversation on Decision-Making Outcomes. Mayo Clin Proc Innov Qual Outcomes 2021; 5:802-810. [PMID: 34401656 PMCID: PMC8358194 DOI: 10.1016/j.mayocpiqo.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To understand the impact of cost conversations on the following decision-making outcomes: patients' knowledge about their conditions and treatment options, decisional conflict, and patient involvement. PATIENTS AND METHODS In 2020 we performed a secondary analysis of a randomly selected set of 220 video recordings of clinical encounters from trials run between 2007 and 2015. Videos were obtained from eight practice-based randomized trials and one pre-post-prospective study comparing care with and without shared decision-making (SDM) tools. RESULTS The majority of trial participants were female (61%) and White (86%), with a mean age of 56, some college education (68%), and an income greater than or equal to $40,000 per year (75%), and who did not participate in an encounter aided by an SDM tool (52%). Cost conversations occurred in 106 encounters (48%). In encounters with SDM tools, having a cost conversation lead to lower uncertainty scores (2.1 vs 2.6, P=.02), and higher knowledge (0.7 vs 0.6, P=.04) and patient involvement scores (20 vs 15.7, P=.009) than in encounters using SDM tools where cost conversations did not occur. In a multivariate model, we found slightly worse decisional conflict scores when patients started cost conversations as opposed to when the clinicians started cost conversations. Furthermore, we found higher levels of knowledge when conversations included indirect versus direct cost issues. CONCLUSION Cost conversations have a minimal but favorable impact on decision-making outcomes in clinical encounters, particularly when they occurred in encounters aided by an SDM tool that raises cost as an issue.
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Affiliation(s)
- Nataly R. Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Christina M. LaVecchia
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
- School of Arts and Sciences, Neumann University, Aston, PA
| | - Karen M. Fischer
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Celia C. Kamath
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Juan P. Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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11
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Kamath CC, Giblon R, Kunneman M, Lee AI, Branda ME, Hargraves IG, Sivly AL, Bellolio F, Jackson EA, Burnett B, Gorr H, Torres Roldan VD, Spencer-Bonilla G, Shah ND, Noseworthy PA, Montori VM, Brito JP. Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116009. [PMID: 34255051 PMCID: PMC8278261 DOI: 10.1001/jamanetworkopen.2021.16009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown. OBJECTIVE To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations. DESIGN, SETTING, AND PARTICIPANTS This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019. MAIN OUTCOMES AND MEASURES The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation. RESULTS A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent. CONCLUSIONS AND RELEVANCE Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02905032.
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Affiliation(s)
- Celia C. Kamath
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Rachel Giblon
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Marlene Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander I. Lee
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Colorado School of Public Health, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Angela L. Sivly
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Elizabeth A. Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Lois Park, Minnesota
| | - Haeshik Gorr
- Division of General Internal Medicine, Hennepin Health, Minneapolis, Minnesota
| | - Victor D. Torres Roldan
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Peter A. Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Winders T, Maspero J, Callan L, Al-Ahmad M. Perspectives on decisions for treatment and care in severe asthma. World Allergy Organ J 2021; 14:100500. [PMID: 33537114 PMCID: PMC7817505 DOI: 10.1016/j.waojou.2020.100500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/12/2020] [Accepted: 11/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background Severe asthma is a subtype of asthma that can be hard to control, resulting in an exceptional impact on an individual's quality of life. The aim of this review article is to explore the misalignment of perceptions of severe asthma among different stakeholders to identify how to reduce burden and improve delivery of care. Results The misalignment of perspectives is best reflected in randomised controlled trials (RCTs) in asthma treatments, which are often designed for regulatory approval with a focus on exacerbations with no direct input from the individuals that the treatments are designed for. Based on a literature review and the clinical experience of the authors to overcome this disparity, the goals of people with severe asthma need to be incorporated throughout their care, from study design to the day-to-day management of their condition. Improved education for individuals and their support network will provide them with resources and knowledge so that they can effectively communicate their needs to other stakeholders involved in their care. Conclusion/recommendation A collaborative effort from all stakeholders is essential to ensure efficient management of asthma and a reduction in asthma burden on individuals and society.
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Affiliation(s)
- Tonya Winders
- Allergy & Asthma Network/Global Allergy & Airways Patient Platform (GAAPP), Vienna, VA, USA
| | - Jorge Maspero
- Allergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, Argentina
| | - Luke Callan
- Global Market Access and Pricing, AstraZeneca UK Ltd., Cambridge, UK
| | - Mona Al-Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
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Harrington NG, Scott AM, Spencer EA. Working toward evidence-based guidelines for cost-of-care conversations between patients and physicians: A systematic review of the literature. Soc Sci Med 2020; 258:113084. [DOI: 10.1016/j.socscimed.2020.113084] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/14/2020] [Accepted: 05/22/2020] [Indexed: 01/29/2023]
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Kaal KJ, Bansback N, Hudson M, Anis A, Koehn C, Harrison M. Patient-provider communication about medication cost in rheumatoid arthritis. Clin Rheumatol 2020; 40:93-100. [PMID: 32506315 DOI: 10.1007/s10067-020-05188-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/08/2020] [Accepted: 05/19/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To examine the perceived importance and frequency with which out-of-pocket medication costs are discussed between rheumatologists and patients with rheumatoid arthritis (RA) in Canada. METHODS A cross-sectional online survey was distributed to patients with RA and rheumatologists; both were asked to rate their perceived importance of discussing medication costs, and how often these discussions occurred. Predictors of (1) patients discussing costs with their rheumatologist and (2) the perceived importance of discussing medication cost for patients were explored. RESULTS Seventy-eight patients and 64 rheumatologists completed the survey; 68% patients and 75% of physicians rated the perceived importance of discussing medication costs as "quite" or "very important"; 22% of patients reported never talking about medication cost, but no physicians reported never discussing costs with patients. The only predictor of talking about cost among patients (at 10% level) was whether they perceived it as highly important (p = 0.058). Higher perceived importance of discussing out-of-pocket costs was associated with a more positive attitude to shared decision-making (p = 0.044). CONCLUSION Discussions about cost do not always happen, even with diseases with potentially high medication costs like RA. Cost was more likely to be discussed by patients who perceived it as "very important," suggesting the onus might be on patients to initiate these conversations. Without any significant predictors regarding what may make physicians more likely to think it was important to discuss medication costs, there is a need to reinforce recommendations that all physicians seek to discuss costs with all of their patients when suggesting medications. Key Points • There is a need for patients and physicians to discuss costs in the treatment decision-making process. Our findings suggest this does not always happen. • Among patients, medication cost was more likely to be discussed by those who perceived it as "very important" and higher perceived importance of discussing out-of-pocket costs was associated with a more positive attitude to shared decision-making. • Our results did not reveal any significant predictors regarding what may make physicians more likely to think it was important to discuss medication costs, suggesting that there is a need to reinforce recommendations that all physicians seek to discuss medication costs with all of their patients when suggesting medications.
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Affiliation(s)
- K Julia Kaal
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,St. Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Marie Hudson
- Division of Rheumatology, Jewish General Hospital and Lady Davis Institute, and Department of Medicine, McGill University, Montreal, QC, Canada
| | - Aslam Anis
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,St. Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Cheryl Koehn
- Arthritis Consumer Experts/JointHealth, Vancouver, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada. .,St. Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Arthritis Research Canada, Richmond, Canada.
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Skaljic M, Patel IH, Pellegrini AM, Castro VM, Perlis RH, Gordon DD. Prevalence of Financial Considerations Documented in Primary Care Encounters as Identified by Natural Language Processing Methods. JAMA Netw Open 2019; 2:e1910399. [PMID: 31469397 PMCID: PMC6724154 DOI: 10.1001/jamanetworkopen.2019.10399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Quantifying patient-physician cost conversations is challenging but important as out-of-pocket spending by US patients increases and patients are increasingly interested in discussing costs with their physicians. OBJECTIVE To characterize the prevalence of financial considerations documented in narrative clinical records of primary care encounters and their association with patient-level features. DESIGN, SETTING, AND PARTICIPANTS This cohort study applied natural language processing to narrative clinical notes obtained from electronic health records for adult primary care visits. Participants included patients aged 18 years and older with at least 1 primary care visit for an annual preventive examination at outpatient clinics at a US academic health system between January 2, 2008, and July 30, 2013. Data were analyzed in March 2019. MAIN OUTCOMES AND MEASURES Presence of financial content documented in narrative clinical notes. RESULTS The data set included 222 457 primary care visits for 46 244 individuals aged 18 years and older; 30 556 patients (60.1%) were female, 27 869 patients (60.3%) were white, and the mean (SD) age was 51.3 (17.7) years. In total, 6058 patients (13.1%) had at least 1 narrative clinical note indicating a financial conversation with their physician. In fully adjusted regression models, the odds of having a financial note were greater among patients with Medicare (odds ratio [OR], 1.27; 95% CI, 1.15-1.41; P < .001) or Medicaid (OR, 1.43; 95% CI, 1.25-1.64; P < .001) insurance, those residing in zip codes with lower median income (OR, 0.97; 95% CI, 0.96-0.98; P < .001), black individuals (OR, 1.40; 95% CI, 1.28-1.53; P < .001), Hispanic individuals (OR, 1.10; 95% CI, 1.01-1.20; P = .03), and those who were unmarried (OR, 1.23; 95% CI, 1.15-1.33; P < .001). CONCLUSIONS AND RELEVANCE Cost considerations were more likely to be noted in annual preventive examinations than previously observed in intensive care unit admissions, but still infrequently. Associations with particular patient subgroups may indicate differential financial burden or willingness to discuss financial concerns.
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Affiliation(s)
- Meliha Skaljic
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ihsaan H. Patel
- Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School, Cambridge, Massachusetts
| | - Amelia M. Pellegrini
- Center for Quantitative Health, Division of Clinical Research, Massachusetts General Hospital, Harvard Medical School, Boston
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Victor M. Castro
- Center for Quantitative Health, Division of Clinical Research, Massachusetts General Hospital, Harvard Medical School, Boston
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Roy H. Perlis
- Center for Quantitative Health, Division of Clinical Research, Massachusetts General Hospital, Harvard Medical School, Boston
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Deborah D. Gordon
- Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School, Cambridge, Massachusetts
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Parikh TJ, Helfrich CD, Quiñones AR, Marshall-Fabien GL, Makaroun LK, Black MA, Thielke SM. Cost-related delay in filling prescriptions and health care ratings among medicare advantage recipients. Medicine (Baltimore) 2019; 98:e16469. [PMID: 31374008 PMCID: PMC6708951 DOI: 10.1097/md.0000000000016469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Despite higher health care needs, older adults often have limited and fixed income. Approximately a quarter of them report not filling or delaying prescription medications due to cost (cost-related prescription delay, CRPD). To ascertain the association between CRPD and satisfaction with health care, secondary analysis of the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Advantage Survey was performed.Regression models quantified the association between CRPD and rating of personal doctor, specialist, and overall health care. Models were adjusted for demographic, health-related, and socioeconomic characteristics. 274,996 Medicare Advantage enrollees were mailed the CAHPS survey, of which 101,910 (36.8%) returned a survey that had responses to all the items we analyzed. CRPD was assessed by self-report of delay in filling prescriptions due to cost. Health care ratings were on a 0-10 scale. A score ≤ 5 was considered a poor rating of care.In unadjusted models, CRPD more than doubled the relative risk (RR) for poor ratings of personal doctor (RR 2.34), specialist (RR 2.14), and overall health care (RR 2.40). Adjusting for demographics and health status slightly reduced the RRs to 1.9, but adjusting for low-income subsidy and lack of insurance for medications did not make a difference.CRPD is independently associated with poor ratings of medical care, regardless of health, financial or insurance status. Providers might reduce patients' financial stress and improve patient satisfaction by explicitly discussing prescription cost and incorporating patient priorities when recommending treatments.
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Affiliation(s)
- Toral J Parikh
- Department of Gerontology and Geriatric Medicine, University of Washington, Health Services Research and Development, VA Puget Sound Health Care System
| | - Christian D Helfrich
- Department of Health Services, University of Washington, Health Services Research and Development, VA Puget Sound Health Care System
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University
| | | | - Lena K Makaroun
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | | | - Stephen M Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System
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Affiliation(s)
- Kapil Bhatia
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Eric Y Chang
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Muhammad Bilal
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia
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Carroll JK, Farah S, Fortuna RJ, Lanigan AM, Sanders M, Venci JV, Fiscella K. Addressing Medication Costs During Primary Care Visits: A Before-After Study of Team-Based Training. Ann Intern Med 2019; 170:S46-S53. [PMID: 31060055 DOI: 10.7326/m18-2011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medications contribute to patients' out-of-pocket costs, yet most clinicians do not routinely screen for patients' cost-of-medication (COM) concerns. OBJECTIVE To assess whether a single training session improves COM conversations. DESIGN Before-after cross-sectional surveys of patients and qualitative interviews with clinicians and staff. SETTING 7 primary care practices in 3 U.S. states. PARTICIPANTS In total, 700 patients were surveyed from May 2017 to January 2018: 50 patients per practice before the intervention and another 50 patients per practice after the intervention. Eligibility criteria included age 18 years or older and taking 1 or more long-term medications. Qualitative interviews with 45 staff members were conducted. INTERVENTION A single 60-minute training session for clinicians and staff from each practice on COM importance, team-based screening, and cost-saving strategies. MEASUREMENTS Patient data (demographics, number of long-term medications, total monthly out-of-pocket medication costs, and history of cost-related medication nonadherence) were obtained immediately before and 3 months after the intervention. Practice staff were interviewed 3 months after the intervention. RESULTS A total of 700 patient surveys were completed. Frequency of COM discussion improved in 6 of the 7 practices and remained unchanged in 1 practice. Overall, COM conversations with patients increased from 17% at baseline to 32% postintervention (P = 0.00). There was substantial heterogeneity among sites in before-after differences in patient-reported out-of-pocket COM. Qualitative analyses from key informant interviews showed wide variation in implementation of screening approaches, workflow, adoption of a team-based approach, and strategies for addressing COM. LIMITATION It is not known whether improvements in COM conversations were sustained beyond 3 months. CONCLUSION A single team training to screen and address patients' medication cost concerns improved COM discussions over the short term. Further research is needed to assess sustained effects and impact on patient costs and medication adherence and to determine whether more intensive, scalable interventions are needed. PRIMARY FUNDING SOURCE Robert Wood Johnson Foundation.
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Affiliation(s)
| | - Subrina Farah
- University of Rochester, Rochester, New York (S.F., M.S.)
| | - Robert J Fortuna
- Center for Primary Care, University of Rochester, Rochester, New York (R.J.F.)
| | - Angela M Lanigan
- National Research Network, American Academy of Family Physicians, Leawood, Kansas (A.M.L.)
| | | | - Jineane V Venci
- University of Rochester Medical Center, Rochester, New York (J.V.V., K.F.)
| | - Kevin Fiscella
- University of Rochester Medical Center, Rochester, New York (J.V.V., K.F.)
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Fox KS, Gray CE, Williamson ME, MacKenzie JA. Using Public Cost Information During Low Back Pain Visits: A Qualitative Study. Ann Intern Med 2019; 170:S93-S102. [PMID: 31060060 DOI: 10.7326/m18-2223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients desire information about health care costs because they are increasingly responsible for these costs. Public Web sites that offer cost information could inform provider-patient discussions of costs at the point of care. OBJECTIVE To evaluate tools to facilitate the use of publicly available cost information during clinical visits for low back pain (LBP). DESIGN Qualitative study using individual and group interviews and surveys. SETTING 6 rural primary care practices in 2 health systems in Maine. PARTICIPANTS Practice staff (n = 50) and adult patients with LBP (n = 72). INTERVENTION Participating health systems and practices were offered financial incentives, a series of trainings, and technical assistance to pilot tools for discussing costs of LBP care using CompareMaine.org, Maine's cost and quality transparency Web site. MEASUREMENTS Integration of tools into workflow, awareness and value to providers, and patient experience were identified through 11 group interviews with practice staff (n = 25) and health system leaders (n = 11), provider (n = 25), and patient (n = 47) surveys; patient interviews (n = 5); and administrative data. RESULTS The intervention increased provider and consumer awareness of CompareMaine.org, but minimally changed use in clinical discussions as a result of fewer-than-expected patients with LBP, limited system support, workflow barriers, and providers' reluctance to adopt the tools because of perceptions of limited value for their patients. In contrast, patients valued cost conversations and found the tools useful, and over one half reported intending to use CompareMaine.org during future care decisions. LIMITATIONS Generalizability was limited by the small number of practices and participants. Lower-than-anticipated participation precluded examination of the effect of the tool on the frequency of cost-of-care conversations. CONCLUSION This multicomponent intervention to introduce publicly reported cost information into LBP clinical discussions had low provider uptake. Whereas cost conversations and CompareMaine.org were perceived as useful by participating patients with LBP, providers were uncomfortable discussing cost variation at the point of care. Successful use of public cost information during clinical visits will require normalizing use to a broader group of patients and greater provider outreach and health system engagement. PRIMARY FUNDING SOURCE Robert Wood Johnson Foundation.
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Affiliation(s)
- Kimberley S Fox
- Cutler Institute for Health and Social Policy, University of Southern Maine, Portland, Maine (K.S.F., C.E.G., M.E.W., J.A.M.)
| | - Carolyn E Gray
- Cutler Institute for Health and Social Policy, University of Southern Maine, Portland, Maine (K.S.F., C.E.G., M.E.W., J.A.M.)
| | - Martha Elbaum Williamson
- Cutler Institute for Health and Social Policy, University of Southern Maine, Portland, Maine (K.S.F., C.E.G., M.E.W., J.A.M.)
| | - Jennifer A MacKenzie
- Cutler Institute for Health and Social Policy, University of Southern Maine, Portland, Maine (K.S.F., C.E.G., M.E.W., J.A.M.)
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Erwin K, Fitzpatrick V, Norell S, Gilliam M. Development of a Framework and Tool to Facilitate Cost-of-Care Conversations With Patients During Prenatal Care. Ann Intern Med 2019; 170:S62-S69. [PMID: 31060059 DOI: 10.7326/m18-2207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Studies show that patients want to engage in cost-of-care conversations and factor costs into the formulation of care plans. Low-income patients are particularly likely to defer care because of costs, suggesting that cost-of-care conversations may be an important factor in health equity. Little guidance is available to clinicians and health systems for how to integrate effective cost-of-care conversations into clinical practice or to address specific cost needs of low-income patients. OBJECTIVE To develop a framework and tool to assist cost-of-care conversations with low-income patients during prenatal care. DESIGN A qualitative study using human-centered design methods. SETTING University medical center-based obstetrics-gynecology (ob-gyn) practice. PARTICIPANTS 20 pregnant or recently postpartum women, 16 clinicians, and 8 support and executive staff. RESULTS Pregnant women accumulate substantial indirect costs that interfere with treatment adherence and stress patients and their relationships. Frequency and duration of appointments are primary drivers of indirect costs; the burden is exacerbated by not knowing these costs in advance and disproportionately affects low-income patients. Working with ob-gyn clinicians, staff, and patients, a paper-based tool was developed to help patients forecast treatment demands and indirect costs, and to help clinicians introduce and standardize cost conversations. LIMITATIONS Data were collected from a small number of stakeholders in a single clinical setting that may not be generalizable to other settings. The tool has not been tested for effects on adherence or clinical outcomes. CONCLUSION A communication tool that helps pregnant patients understand their care plan and anticipate indirect costs can promote cost-of-care conversations between clinicians and low-income patients. PRIMARY FUNDING SOURCE Robert Wood Johnson Foundation.
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Affiliation(s)
- Kim Erwin
- University of Illinois at Chicago (K.E., S.N.)
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Miranda AC, Serag-Bolos ES, Cooper JB. Cost-related medication underuse: Strategies to improve medication adherence at care transitions. Am J Health Syst Pharm 2019; 76:560-565. [PMID: 31361859 DOI: 10.1093/ajhp/zxz010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Aimon C Miranda
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida, College of Pharmacy, Tampa, FL
| | - Erini S Serag-Bolos
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida, College of Pharmacy, Tampa, FL
| | - Julie B Cooper
- Department of Clinical Sciences, Fred Wilson School of Pharmacy at High Point University, High Point, NC
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Davis SR, Tudball J, Flynn A, Lembke K, Zwar N, Reddel HK. "You've got to breathe, you know" - asthma patients and carers' perceptions around purchase and use of asthma preventer medicines. Aust N Z J Public Health 2019; 43:207-213. [PMID: 30727033 DOI: 10.1111/1753-6405.12865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore influences on patients' purchase and use of asthma preventer medicines and the perceived acceptability of financial incentives via reduced patient co-payments. METHODS Semi-structured telephone or face-to-face interviews were conducted with adults and carers of children with asthma. Interviews were recorded, transcribed verbatim and coded. Data were analysed using thematic analysis via grounded theory. RESULTS Twenty-four adults and 20 carers for children aged 3-17 years with asthma were interviewed. For medicines choice, most participants did not consider themselves the primary decision-maker; cost of medicines was an issue for some, but effectiveness was described as more important. For adherence, cost, side-effects, perceived benefit and patient behaviours were important. CONCLUSIONS Patient barriers to adherence with asthma preventer medicines including cost are ongoing. Healthcare professionals need to encourage empathic discussion with patients about cost issues. Implications for public health: Asthma patients and carers could benefit from greater involvement and respect within shared decision-making. Healthcare professionals should be aware that cost may be a barrier for patient adherence, and provided with information about the relative costs of guideline-recommended asthma medicines. Patients and healthcare professionals need education around the efficacy of ICS-alone treatment and the rationale behind co-payments, for initiatives around quality use of medicines to succeed.
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Affiliation(s)
- Sharon R Davis
- Woolcock Institute of Medical Research, University of Sydney, New South Wales
| | | | | | | | - Nicholas Zwar
- School of Medicine; Faculty of Science, Medicine and Health University of Wollongong, New South Wales
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, New South Wales
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Will precision medicine be available for all patients in the near future? Curr Opin Allergy Clin Immunol 2019; 19:75-80. [DOI: 10.1097/aci.0000000000000491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Localio AM, Black HL, Park H, Perez L, Ndicu G, Klusaritz H, Rogers M, Han X, Apter AJ. Filling the patient-provider knowledge gap: a patient advocate to address asthma care and self-management barriers. J Asthma 2018; 56:1027-1036. [PMID: 30285499 DOI: 10.1080/02770903.2018.1520864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Introduction: In an ongoing study, a new clinical role adapted from a patient navigator called the patient advocate (PA) met with patients before medical visits, attended appointments and afterwards reviewed provider instructions. This qualitative analysis examines the perspectives of PAs and providers regarding their experiences with patients to understand how a PA can help patients and providers achieve better asthma control. Methods: PAs recorded journal entries about their experiences with patients. Provider focus groups and interviews were conducted by researchers and transcribed. Analysis was based on the Grounded Theory approach for qualitative research, using open and then focused coding. Two researchers independently coded these sources until intercoder agreement was achieved. Results: Upon review of 31 journal entries on PA experiences with 24 patients and transcripts from 2 provider focus groups and 12 provider interviews, 5 themes emerged surrounding asthma care and self-management: medication adherence, follow-up, communication, social determinants of health and time. While patients shared with PAs specific socioeconomic barriers to medication adherence and follow-up, providers often did not know about these problems and cited barriers to communication. Time restrictions on medical visits further limited communication. Conclusions: Perspectives reported here illustrate a gap in knowledge and understanding between patients and providers. The PA's unique relationship with patients and presence inside and outside of medical visits allowed them to learn contextual patient information unknown to providers. PAs and providers cited numerous ways PAs can help to improve patient-provider mutual understanding.
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Affiliation(s)
- Anna M Localio
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heather L Black
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hami Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luzmercy Perez
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Grace Ndicu
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heather Klusaritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Rogers
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaoyan Han
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrea J Apter
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Alzaye R, Chaar BB, Basheti IA, Saini B. General Practitioners' experiences of asthma management in culturally and linguistically diverse populations. J Asthma 2018; 56:642-652. [PMID: 29720013 DOI: 10.1080/02770903.2018.1472280] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The purpose of this study was to explore General Practitioners' experiences and perspectives about asthma management of culturally and linguistically diverse (CALD) people with asthma, particularly with reference to Arabic-speaking patients with low English proficiency (LEP). METHODS Semi-structured interviews guided by an interview protocol were conducted with general practitioners who deal with CALD patients with asthma. Participants were recruited from medical practices in Melbourne, Australia. Interviews were recorded and transcribed verbatim, followed by an inductive thematic analysis. RESULTS Data saturation was achieved after 21 interviews. Interviews lasted on average 30 minutes. Thematic analyses of the interview transcripts highlighted five key emergent themes: self-autonomy, language issues, accessibility and engagement, health literacy, and cultural/beliefs issues. Many participants highlighted that CALD patients do not self-manage their asthma. Miscommunication was mentioned by some participants as stemming from language barriers. Patients' difficulty in engagement with the health system, lower accessibility to health care, social isolation, and non-acclimatization were other issues participants highlighted as problems in providing effective asthma care to CALD patients. Participants reported finding it more difficult to treat CALD patients with asthma compared to local patients. CONCLUSION General practitioners perceived that treating culturally and linguistically diverse patients with asthma is difficult and many key barriers were observed to affect treatment. Cultural competence training for health professionals, as well as improving asthma and health system awareness in CALD patients with asthma and their carers, are key interventions that may address asthma management gaps in CALD patients.
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Affiliation(s)
- Reem Alzaye
- a University of Sydney - Camperdown and Darlington Campus, Pharmacy , Sydney , Australia
| | - Betty Bouad Chaar
- b The University of Sydney , Pharmacy, Bldg A15 Faculty of Pharmacy, The University of Sydney , NSW , Sydney , Australia
| | - Iman A Basheti
- c Applied Science University , Clinical Pharmacy and Therapeutics , Shafa Badran , Amman , Jordan
| | - Bandana Saini
- d University of Sydney - Camperdown and Darlington Campus , Pharmacy, Camperdown Campus, Faculty of Pharmacy , Sydney , Australia
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Assessing Patient and Provider Perceptions of Factors Associated with Patient Engagement in Asthma Care. Ann Am Thorac Soc 2018; 14:659-666. [PMID: 28128966 DOI: 10.1513/annalsats.201608-602oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE National quality improvement initiatives emphasize building partnerships between patients and providers by promoting patient engagement through communication, shared decision-making, and self-care skills. Efforts to promote patient engagement are especially important for people with asthma. To cultivate effective partnerships in asthma care, patients and providers may benefit from understanding each other's values and perceptions regarding treatment goals, shared decision-making, as well as barriers to optimal care and outcomes. OBJECTIVES We conducted a survey study to assess and compare asthma patient and provider perceptions of factors that are associated with effective partnerships and patient engagement. METHODS Surveys were administered to adult patients with poorly controlled asthma (n = 328) and their physicians (n = 40) before they participated in collaborative learning sessions held in 40 allergy and immunology practices across the United States. The surveys included items for both groups to report their asthma-related treatment goals and perceptions about information needs and knowledge, shared decision-making, and barriers to medication adherence. RESULTS Providers rated their knowledge about different aspects of their patients' health status (on a scale from 1 = poor knowledge to 5 = excellent knowledge). The lowest percentages of ratings 4 and 5 were for knowledge about patients' financial status (29%), adherence (42%), lifestyle (46%), and workplace situation (46%). The highest percentages of ratings 4 and 5 were for knowledge about patients' exacerbation history (75%), smoking status (76%), hospitalization history (79%), and comorbidities (79%). The percentages of patients and providers, respectively, who indicated the following treatment goals as important differed significantly: preventing exacerbations (62% and 83%; P = 0.01), preventing emergency department visits (44% and 76%; P < 0.01), and improving ability to perform daily activities (69% and 48%; P < 0.01). However, there were no significant differences in percentages of provider-reported goals and goals that providers estimated their patients would indicate as important. Disconnects were also observed for perceived barriers to asthma medication adherence. CONCLUSIONS The observed disconnects in patient and provider perceptions may inform strategies for cultivating effective partnerships and patient engagement to improve care quality and outcomes for people with asthma.
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Wagner C, Murphy L, Harkenrider J, Darilek S, Soto-Torres E, Stein Q, Hoskovec J. Genesurance Counseling: Patient Perspectives. J Genet Couns 2018; 27:814-822. [DOI: 10.1007/s10897-018-0211-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 01/02/2018] [Indexed: 11/24/2022]
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Liu Z, Zhang Y, Tian L, Sun B, Chang Q, Zhao Y. Application of latent class analysis in assessing the competency of physicians in China. BMC MEDICAL EDUCATION 2017; 17:208. [PMID: 29132410 PMCID: PMC5683211 DOI: 10.1186/s12909-017-1039-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/02/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND The physicians' competency is an important public health issue around the world. Several international organizations have taken the lead in examining the competencies required to be a physician. The purpose of this study is to identify subgroups of physicians' competency based upon the importance results of competency evaluation and provide a scientific basis for the qualitative research of the competency of physicians. METHODS A cross-sectional study was conducted on a large population-based sample in 31 provinces, autonomous regions and municipalities directly under the central government in China. The latent class analysis was performed to identify patterns of physicians' competency using M-plus software. RESULTS In this study, the latent class analysis was adopted to identify the appropriate number of distinct latent classes of physicians' competency based on eight competency dimensions, and a four-class model best fit the data, which are excellent competency group, lack of professionalism competency group, individual competency driven group, and lack of competency cognitive group. Therefore, 6247 physicians can be divided into four latent classes based on the importance results of competency evaluation, and the number of each class is 5684, 284, 215 and 64, respectively. CONCLUSION These findings suggested that latent class analysis can be used to study the competency of physicians, and four distinct subgroups were identified. Therefore, we can effectively understand the patterns of physicians' competency, and the health administrative departments could utilize more specific measures according to their different competency subgroups, and providing individualized training schemes in the future training and management of physicians.
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Affiliation(s)
- Zhuang Liu
- School of Public Health, China Medical University, Shenyang, Liaoning China
| | - Yue Zhang
- School of Public Health, China Medical University, Shenyang, Liaoning China
| | - Lei Tian
- Research Center for Medical Education, China Medical University, Shenyang, Liaoning China
| | - Baozhi Sun
- Research Center for Medical Education, China Medical University, Shenyang, Liaoning China
| | - Qing Chang
- Department of Clinical Epidemiology, Shengjing Hospital, China Medical University, No.36, Sanhao Street, Heping District, Shenyang, Liaoning Province 110004 People’s Republic of China
| | - Yuhong Zhao
- Department of Clinical Epidemiology, Shengjing Hospital, China Medical University, No.36, Sanhao Street, Heping District, Shenyang, Liaoning Province 110004 People’s Republic of China
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Takemura M, Nishio M, Fukumitsu K, Takeda N, Ichikawa H, Asano T, Tomita H, Kanemitsu Y, Yoshikawa K, Niimi A. Optimal cut-off value and clinical usefulness of the Adherence Starts with Knowledge-12 in patients with asthma taking inhaled corticosteroids. J Thorac Dis 2017; 9:2350-2359. [PMID: 28932539 DOI: 10.21037/jtd.2017.06.115] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Non-adherence to inhalation regimens is common in asthmatic patients. The Adherence Starts with Knowledge-12 (ASK-12) survey was developed to detect and address patient-specific barriers to medication adherence. Our objective is to investigate the clinical usefulness of the ASK-12 for assessing and addressing adherence to inhalation therapy in asthma. METHODS The ASK-12 was administered to 138 asthmatic patients. Using pharmacy-refill data, we examined the cut-off value of the ASK-12 to identify patients who were non-adherent to inhalation regimens and identify factors associated with non-adherence. To verify the usefulness of the ASK-12, inhalation regimens were prospectively switched to less-expensive and simpler (once-daily) dosing regimens in eight non-adherent asthmatic patients who reported specific-barriers in "inconvenience of twice-daily inhaler use" and "cost". RESULTS Valid responses were received from 114 (82.6%) patients. A significant correlation was found between pharmacy-refill rates and the ASK-12 total score (r=-0.55, P<0.0001). The optimal cut-off value of the ASK-12 total score to discriminate non-adherent patients (defined by pharmacy-refill rate <80%) was 23, with 71.4% specificity and 93.3% sensitivity. Using this value, 52 (45.6%) patients were classified as non-adherent. Univariate followed by multivariate analysis identified younger age as a predictor of non-adherence to inhalation regimens (odds ratio, 2.67; 95% CI, -0.95 to -0.06; P=0.027). Switching inhaled medicines in eight patients resulted in significant improvements in both ASK-12 scores and asthma control. CONCLUSIONS The ASK-12 is a brief, practical, and clinically useful measure for assessing and addressing adherence to inhalation regimens in asthma.
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Affiliation(s)
- Masaya Takemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Masayuki Nishio
- Department of Respiratory Medicine, Social Medical Corporation Kojunkai, Daido Hospital, Daido Clinic, Nagoya, Japan
| | - Kensuke Fukumitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Norihisa Takeda
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Hiroya Ichikawa
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Takamitsu Asano
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Hiroki Tomita
- Department of Respiratory Medicine, Social Medical Corporation Kojunkai, Daido Hospital, Daido Clinic, Nagoya, Japan
| | - Yoshihiro Kanemitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Kosho Yoshikawa
- Department of Respiratory Medicine, Social Medical Corporation Kojunkai, Daido Hospital, Daido Clinic, Nagoya, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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Shakshuki A, Agu RU. Improving the Efficiency of Respiratory Drug Delivery: A Review of Current Treatment Trends and Future Strategies for Asthma and Chronic Obstructive Pulmonary Disease. Pulm Ther 2017; 3:267-281. [PMID: 32026344 PMCID: PMC6964260 DOI: 10.1007/s41030-017-0046-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 12/23/2022] Open
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous airway diseases associated with significant morbidity and mortality. Pharmacological treatment is delivered primarily through the inhalation route using various devices. Optimal disease control is highly dependent upon patient adherence. Both patients with asthma and COPD are prone to exacerbations leading to hospitalization, which can significantly impact quality of life. Poor adherence is a complex and multifactorial problem that does not have one simple solution. However, it is the biggest risk factor for exacerbations and consequently high healthcare utilization. This review discusses the complex and multifactorial obstacles that impact patient adherence as well as the effect on overall treatment outcomes and healthcare utilization. We also critically examined and compared relatively recent improvements in breath-activated pressurized metered dose inhalers, dry powder inhalers, and e-technology in asthma and COPD. Finally, future treatment strategies for better patient compliance such as personalized medicine and the importance of decision-making between patients and physicians were highlighted.
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Affiliation(s)
- Ayah Shakshuki
- Biopharmaceutics and Drug Delivery Lab, College of Pharmacy, Halifax, Canada
| | - Remigius U Agu
- Biopharmaceutics and Drug Delivery Lab, College of Pharmacy, Halifax, Canada.
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How Primary Care Physicians Integrate Price Information into Clinical Decision-Making. J Gen Intern Med 2017; 32:81-87. [PMID: 27561735 PMCID: PMC5215149 DOI: 10.1007/s11606-016-3805-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 05/04/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Little is known about how primary care physicians (PCPs) in routine outpatient practice use paid price information (i.e., the amount that insurers finally pay providers) in daily clinical practice. OBJECTIVE To describe the experiences of PCPs who have had paid price information on tests and procedures for at least 1 year. DESIGN Cross-sectional study using semi-structured interviews and the constant comparative method of qualitative analysis. PARTICIPANTS Forty-six PCPs within an accountable care organization. INTERVENTION Via the ordering screen of their electronic health record, PCPs were presented with the median paid price for commonly ordered tests and procedures (e.g., blood tests, x-rays, CTs, MRIs). APPROACH We asked PCPs for (a) their "gut reaction" to having paid price information, (b) the situations in which they used price information in clinical decision-making separate from or jointly with patients, (c) their thoughts on who bore the chief responsibility for discussing price information with patients, and (d) suggestions for improving physician-targeted price information interventions. KEY RESULTS Among "gut reactions" that ranged from positive to negative, all PCPs were more interested in having patient-specific price information than paid prices from the practice perspective. PCPs described that when patients' out-of-pocket spending concerns were revealed, price information helped them engage patients in conversations about how to alter treatment plans to make them more affordable. PCPs stated that having price information only slightly altered their test-ordering patterns and that they avoided mentioning prices when advising patients against unnecessary testing. Most PCPs asserted that physicians bear the chief responsibility for discussing prices with patients because of their clinical knowledge and relationships with patients. They wished for help from patients, practices, health plans, and society in order to support price transparency in healthcare. CONCLUSIONS Physician-targeted price transparency efforts may provide PCPs with the information they need to respond to patients' concerns regarding out-of-pocket affordability rather than that needed to change test-ordering habits.
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Nguyen HV, Nadkarni NV, Sankari U, Mital S, Lye WK, Tan NC. Association between asthma control and asthma cost: Results from a longitudinal study in a primary care setting. Respirology 2016; 22:454-459. [PMID: 27862645 DOI: 10.1111/resp.12930] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/12/2016] [Accepted: 08/12/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Asthma control can be assessed with the Asthma Control Test (ACT) and a score of 20 or higher indicates good asthma control. Patients pay for their consultation and treatment in the fee-for-service primary healthcare system in Singapore. We hypothesized that achieving asthma control would result in lower asthma costs through reduced acute exacerbations, fewer physician consultations and lower lost productivity. The study compared the healthcare costs of patients who achieved asthma control and those with suboptimal asthma control based on ACT scores. Factors influencing asthma control and healthcare expenditure over time were also examined. METHODS A total of 736 patients were enrolled into an asthma care programme in two polyclinics during 2008 and 2013. Direct costs of asthma management were derived from the frequency of polyclinic consultations, medication costs and hospitalization. Indirect costs were estimated from lost workdays due to exacerbations. The generalized estimating equation (GEE) approach was used to longitudinally model the factors associated with total healthcare expenditure. RESULTS Patients with asthma control spent S$48 (US$36) more per doctor visit on asthma drugs (P < 0.01) but incurred S$65 (US$48) less per doctor visit in total costs (P < 0.01) than those with suboptimal asthma control. The savings from achieving asthma control for obese patients were greater than for normal-weight patients (S$42 or the equivalent of US$31; P < 0.05). CONCLUSION Optimal asthma control was associated with reduced healthcare costs. An effective treatment regimen should also consider other modifiable factors such as weight control to achieve asthma control and eventually reduce asthma costs.
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Affiliation(s)
- Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | | | - Usha Sankari
- Department of Research, SingHealth Polyclinics, Singapore
| | - Shweta Mital
- Health Services and Systems Research, Duke NUS Medical School, Singapore
| | - Weng K Lye
- Centre for Quantitative Medicine, Duke NUS Medical School, Singapore
| | - Ngiap C Tan
- Department of Research, SingHealth Polyclinics, Singapore.,Health Service Research Centre, Duke NUS Medical School, Singapore
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Chérrez Ojeda I, Calderon JC, Mori J, Colombaro D, Braido F, Soria E, Cherrez A. Patient-physician relationship in the management of asthma: Multicentric approach in Latin America. J Asthma 2016; 53:751-60. [PMID: 27042878 DOI: 10.3109/02770903.2016.1145691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate and compare how Latin American physicians rate themselves on the use of communication strategies in the management of asthma patients, and to explore their personal experience and opinions on asthma treatment. METHODS A cross-sectional survey of physicians attending international medical conferences in Latin America was conducted. Participants rated themselves on frequency of use of 24 communication strategies using a 5-point Likert scale. For statistical analysis, self-rating responses were divided into two classes: very likely to (always or often on a Likert scale) and not very likely to (sometimes, seldom or never on a Likert scale). Participants also answered 4 multiple choice questions about management of asthma patients. Overall responses were analyzed using descriptive statistics and Chi-square. Multivariate logistic regression analysis was performed to evaluate self-ratings by country, gender, practice area (GP or specialist) and age. RESULTS A total of 304 physicians from Ecuador, Argentina and Peru responded. Overall, the majority of respondents rated themselves very likely to use 21 of the 24 communication strategies. Some significant differences were observed in self-ratings among physicians from different countries, between males and females, between GPs and specialists and between younger and older physicians. Responses to the multiple choice questions showed that 79.6% of the respondents believed that most or almost all patients can achieve asthma control. CONCLUSIONS A high percentage of the Latin American physicians surveyed rated themselves very likely to use good communication strategies when managing asthma patients and felt that asthma control can be achieved in most or almost all patients.
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Affiliation(s)
- Iván Chérrez Ojeda
- a School of Medicine, Universidad de Especialidades Espíritu Santo , Guayaquil , Ecuador.,b Respiralab , Guayaquil , Ecuador
| | | | | | | | - Fulvio Braido
- e Allergy and Respiratory Diseases Department , University of Genoa , Genoa , Italy
| | - Edwin Soria
- f Corporacion Medica del Sur , Quito , Ecuador
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Hunter WG, Hesson A, Davis JK, Kirby C, Williamson LD, Barnett JA, Ubel PA. Patient-physician discussions about costs: definitions and impact on cost conversation incidence estimates. BMC Health Serv Res 2016; 16:108. [PMID: 27036177 PMCID: PMC4815215 DOI: 10.1186/s12913-016-1353-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/17/2016] [Indexed: 02/08/2023] Open
Abstract
Background Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Methods Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests. Results Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost/Coverage, Cost of Illness, respectively; P < 0.001); depression: 30, 38, 43 %, (P < 0.001); and rheumatoid arthritis, 26, 33, 35 %, (P < 0.001). Conclusions The estimated incidence of physician-patient cost conversation varied significantly depending on the definition used. Our findings and proposed definitions may assist in retrospective interpretation and prospective design of investigations on this topic. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1353-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wynn G Hunter
- Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA.
| | - Ashley Hesson
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - J Kelly Davis
- Duke University, Fuqua School of Business, Durham, NC, USA
| | | | | | | | - Peter A Ubel
- Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA.,Duke University, Fuqua School of Business, Durham, NC, USA.,Duke University, Sanford School of Public Policy, Durham, NC, USA
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The black box of out-of-pocket cost communication. A path toward illumination. Ann Am Thorac Soc 2015; 11:1608-9. [PMID: 25549026 DOI: 10.1513/annalsats.201410-475ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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