Interventions supporting cost conversations between patients and clinicians: A systematic review

BACKGROUND AND AIM

Discussing cost during medical encounters may decrease the financial impact of medical care on patients and align their treatment plans with their financial capacities. We aimed to examine which interventions exist and quantify their effectiveness to support cost conversations.

METHODS

Several databases were queried (Embase; Ovid MEDLINE(R); Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily; the Cochrane databases; and Scopus) from their inception until January 31, 2020 using terms such as "clinician*", "patient*", "cost*", and "conversation*". Eligibility assessment, data extraction and risk of bias assessment were performed independently and in duplicate. We extracted study setting, design, intervention characteristics and outcomes related to patients, clinicians and quality metrics.

RESULTS

We identified four studies (1327 patients) meeting our inclusion criteria. All studies were non-randomised and conducted in the United States. Three were performed in a primary care setting and the fourth in an oncology. Two studies used decision aids that included cost information; one used a training session for health care staff about cost conversations, and the other directly delivered information regarding cost conversations to patients. All interventions increased cost-conversation frequency. There was no effect on out-of-pocket costs, satisfaction, medication adherence or understanding of costs of care.

CONCLUSION

The body of evidence is small and comprised of studies at high risk of bias. However, an increase in the frequency of cost conversations is consistent. Studies with higher quality are needed to ascertain the effects of these interventions on the acceptability, frequency and quality of cost conversations.

SUN-432 Utilizing Patient Online Forums to Capture Experiences and Perceptions Associated with the Use of Desiccated Thyroid Extract

Background: It is estimated that 10-25% of patients with hypothyroidism use desiccated thyroid extract (DTE) as their primary thyroid hormone replacement medication, despite concerns about the risk of thyrotoxicosis associated with DTE use. It is unclear why many patients prefer the use of DTE as a thyroid hormone replacement formulation over guideline-concordant therapies such as levothyroxine (LT4). Methods: We conducted a mixed-methods study by analyzing patient-reported information from patient online forums to better understand patient preferences for and attitudes toward the use of DTE to treat hypothyroidism. We searched the 10 most popular patient forums based on number of users (WebMD, Topix, Health questions, Patients like me, Drugs.com, Endocrine Web, Everyday Health, Talk Health Partnership, Spark People and Patients.info) using the key terms: desiccated thyroid extract, desiccated thyroid treatment, thyroid USP, commercial names of DTE (Armour Thyroid^® or Natural Thyroid^®), thyroid extract, AND hypothyroidism. Unique posts were retrieved from those websites between each forum’s inception to March 2018. From these posts, we extracted descriptive information on patient demographics and clinical characteristics and qualitatively analyzed posts’ content to further explore patient perceptions on DTE and other thyroid hormone replacement therapies. Results: Unique 1,235 posts were initially retrieved from the included patient forums. After the initial screening, we selected data from three of these forums (WebMD, Patients Like Me, and Drugs.com) based on the completeness of the available information (673 posts). Nearly half (45%) of patients reported that a clinician initially drove their interest in trying DTE. Patients described many reasons for switching from a previous therapeutic approach to DTE, including lack of improvement in symptoms (58%) and the development of side effects (22%). Among a majority of patients, DTE was described as moderately-to-majorly effective overall (81%) and more effective than the previous therapy (77%). The most frequently described benefits associated with DTE use were an improvement in clinical symptoms (56%) as well as a change in overall well-being (34%). One-fifth of patients described side effects related to the use of DTE. Qualitative analysis of posts’ content supported these findings and raised additional issues around the need for individualizing therapy approaches for hypothyroidism as well as difficulties obtaining DTE. Conclusions: Among patients with hypothyroidism, a subset may prefer DTE over guideline-concordant therapies for many reasons, including perceived effectiveness, despite the risks associated with DTE. Future work should incorporate patient-reported outcomes to better elucidate the mechanisms responsible for therapy preferences in this subset of patients.

Crafting Care That Fits: Workload and Capacity Assessments Complementing Decision Aids in Implementing Shared Decision Making

About 42% of adults have one or more chronic conditions and 23% have multiple chronic conditions. The coordination and integration of services for the management of patients living with multimorbidity is important for care to be efficient, safe, and less burdensome. Minimally disruptive medicine may optimize this coordination and integration. It is a patient-centered approach to care that focuses on achieving patient goals for life and health by seeking care strategies that fit a patient’s context and are minimally disruptive and maximally supportive. The cumulative complexity model practically orients minimally disruptive medicine–based care. In this model, the patient workload-capacity imbalance is the central mechanism driving patient complexity. These elements should be accounted for when making decisions for patients with chronic conditions. Therefore, in addition to decision aids, which may guide shared decision making, we propose to discuss and clarify a potential workload-capacity imbalance.

Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review

BACKGROUND

Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient's particular situation. Six SDM key elements can be identified: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences, and making the decision. The International Patient Decision Aid Standards (IPDAS) require that a decision aid (DA) support these key elements. Yet, the extent to which DAs support these six key SDM elements and how this relates to their impact remain unknown.

METHODS

We searched bibliographic databases (from inception until November 2017), reference lists of included studies, trial registries, and experts for randomized controlled trials of DAs in patients with cardiovascular, or chronic respiratory conditions or diabetes. Reviewers worked in duplicate and independently selected studies for inclusion, extracted trial, and DA characteristics, and evaluated the quality of each trial.

RESULTS

DAs most commonly clarified options (20 of 20; 100%) and discussed their harms and benefits (18 of 20; 90%; unclear in two DAs); all six elements were clearly supported in 4 DAs (20%). We found no association between the presence of these elements and SDM outcomes.

CONCLUSIONS

DAs for selected chronic conditions are mostly designed to transfer information about options and their harms and benefits. The extent to which their support of SDM key elements relates to their impact on SDM outcomes could not be ascertained.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42016050320 .

Bone strain magnitude is correlated with bone strain rate in tetrapods: implications for models of mechanotransduction

Hypotheses suggest that structural integrity of vertebrate bones is maintained by controlling bone strain magnitude via adaptive modelling in response to mechanical stimuli. Increased tissue-level strain magnitude and rate have both been identified as potent stimuli leading to increased bone formation. Mechanotransduction models hypothesize that osteocytes sense bone deformation by detecting fluid flow-induced drag in the bone's lacunar-canalicular porosity. This model suggests that the osteocyte's intracellular response depends on fluid-flow rate, a product of bone strain rate and gradient, but does not provide a mechanism for detection of strain magnitude. Such a mechanism is necessary for bone modelling to adapt to loads, because strain magnitude is an important determinant of skeletal fracture. Using strain gauge data from the limb bones of amphibians, reptiles, birds and mammals, we identified strong correlations between strain rate and magnitude across clades employing diverse locomotor styles and degrees of rhythmicity. The breadth of our sample suggests that this pattern is likely to be a common feature of tetrapod bone loading. Moreover, finding that bone strain magnitude is encoded in strain rate at the tissue level is consistent with the hypothesis that it might be encoded in fluid-flow rate at the cellular level, facilitating bone adaptation via mechanotransduction.

Population genetics of a polyploid: is there hybridization between lineages of Hyla versicolor?

Several studies have demonstrated that polyploid species can form recurrently from their progenitors, but few studies have evaluated gene flow between the resultant polyploid lineages. Here we examine the possibility of hybridization between lineages of the tetraploid common gray treefrog (Hyla versicolor). We utilize a polymerase chain reaction (PCR) cloning approach to estimate the genotypes of tetraploid individuals and measure genetic differentiation between (1) sympatric populations of two lineages and (2) allopatric populations of a single lineage. We find that allele frequencies in sympatric populations of two lineages do not differ, suggesting that frogs of these two lineages hybridize in areas where they co-occur.