TY - JOUR
T1 - Cost Conversations about Anticoagulation between Patients with Atrial Fibrillation and Their Clinicians A Secondary Analysis of a Randomized Clinical Trial
AU - Kamath, Celia C.
AU - Giblon, Rachel
AU - Kunneman, Marlene
AU - Lee, Alexander I.
AU - Branda, Megan E.
AU - Hargraves, Ian G.
AU - Sivly, Angela L.
AU - Bellolio, Fernanda
AU - Jackson, Elizabeth A.
AU - Burnett, Bruce
AU - Gorr, Haeshik
AU - Torres Roldan, Victor D.
AU - Spencer-Bonilla, Gabriella
AU - Shah, Nilay D.
AU - Noseworthy, Peter A.
AU - Montori, Victor M.
AU - Brito, Juan P.
N1 - Publisher Copyright:
© 2021 American Medical Association. All rights reserved.
PY - 2021
Y1 - 2021
N2 - 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 decisionmaking (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) agewas 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%) andwere 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.
AB - 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 decisionmaking (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) agewas 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%) andwere 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.
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U2 - 10.1001/jamanetworkopen.2021.16009
DO - 10.1001/jamanetworkopen.2021.16009
M3 - Article
C2 - 34255051
AN - SCOPUS:85109847198
SN - 2574-3805
VL - 4
SP - E2116009
JO - JAMA Network Open
JF - JAMA Network Open
IS - 7
ER -