Shared decision-making, clinician factors associated with whether or not patients/clinicians talk cost

Use of a shared decision-making (SDM) tool, along with other clinician characteristics, was significantly associated with whether patients with atrial fibrillation (AFib) spoke with their clinicians about the cost of anticoagulation therapy, researchers found.

Use of oral anticoagulants, warfarin, and non-vitamin K antagonists or direct oral anticoagulants (DOACs) has been shown to prevent strokes in patients with AFib; however, nearly half of all patients with Afib “do not receive oral anticoagulants, and of those who do initiate treatment, 30% to 50% will discontinue therapy within the first 12 months,” Juan P. Brito, MD, MSc, of the Mayo Clinic in Rochester, Minnesota, and colleagues wrote in JAMA Network Open. One of the most important barriers to anticoagulation is treatment costs, but cost conversations occur infrequently in clinical practice, with only one in three clinicians reporting having such discussions with patients.

In the SDM4AFib multicenter trial, Brito and colleagues “demonstrated that using an SDM conversation tool designed for use during the clinical encounter improved aspects of SDM quality and clinician satisfaction,” the study authors explained. Now, in this secondary analysis, they sought to examine the association of the same SDM tool with the incidence of cost conversations between patients with AFib and their clinicians, as well as patient, clinician, and encounter factors associated with these discussions and the degree to which cost conversations guided treatment choice.

Brito and colleagues found that “cost conversations occurred in 3 of every 4 encounters between patients with AFib and their clinicians. Use of an SDM tool and several clinician characteristics were significantly associated with cost conversations, whereas we could not find significant associations between patient characteristics other than income and the occurrence of cost conversations. Cost is influential in the choice of anticoagulant, but cost conversations were not associated with the selection of more or less expensive options.”

Use of the SDM tool was associated with a 10-fold increase in the odds of having a cost conversation during the clinical encounter, they added.

“These findings can inform further efforts to promote helpful cost conversations in practice,” they argued. “With increasing costs of health care passed on to patients, these conversations are likely to be more widely relevant as patients co-create treatment programs with their clinicians and implement those programs in their lives with sufficient fidelity for them to be effective and safe.”

In an editorial accompanying the study, Ishani Ganguli, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital in Boston, and associate editor of JAMA Network Open, and Nitya Thakore, BA, also of Brigham and Women’s Hospital, argued that even if cost conversations do not directly influence medication choices, there is still “enormous value” in normalizing such conversations in the clinic.

“These conversations continue to carry stigma, especially for historically marginalized populations,” they wrote. “Developing more shared decision-making tools with cost information and offering them at the point of care may lower the activation energy to have these conversations, especially for clinicians who cite lack of knowledge about costs as a barrier or are otherwise less likely to offer them organically. This is not a trivial undertaking given the heterogeneity of cost inputs and the limited time in visits to use the tools. Yet there are clear benefits to folding such tools into standard practice, especially for the many patients who want these conversations but are understandably afraid to ask. Our patients’ health may depend on it.”

The secondary analysis by Brito et al was conducted at five medical centers in the Midwest (3), Alabama (1), and Mississippi (1). Participants consisted of both patients and clinicians—adult patients were eligible if they had a diagnosis of nonvalvular AFib, were at high risk for a thromboembolic event, and were able to read and understand the informed consent document; all clinicians at participating medical centers who regularly had conversations with patients with AFib about anticoagulation were eligible to participate. Patients were enrolled in two cohorts, a start cohort including patients new to anticoagulation and a review cohort of patients receiving ongoing anticoagulation.

The study authors used the Anticoagulation Choice SDM encounter tool, which provides the “patient’s tailored stroke risk at 1 or 5 years with and without anticoagulation using the CHA2DS2-VASc score,” they explained. The tool then compares treatment options by issues important to the patient, including medication use, risk of bleeding, the need for periodic monitoring, reversibility, and estimated out-of-pocket costs.

The final analysis included data from 830 encounters out of 922 enrolled participants. “Patient’s 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,” they explained. “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.”

A total of 419 encounters included the SDM tool, while 411 were given standard care.

Among the findings:

  • “Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] versus 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 versus 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%] versus 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent.”

While the SDM tool was clearly a driver of cost conversations, Brito and colleagues pointed out that the incidence of cost conversations in the standard care arm (63%) was “considerably higher than the incidence reported in other series,” which they argued “may reflect the decisional setting: anticoagulation to prevent AFib-associated strokes involves considering potentially expensive alternatives and implementing treatments with substantial fidelity.”

In their editorial, Ganguli and Thakore noted that the increased rate of cost conversations among female clinicians builds on “substantial evidence that, on average, [female clinicians] conduct longer visits with patients, engage in more shared decision-making, and have more patient-centered communication styles,” differences that are likely attributable to patient expectations, sociocultural norms, and personal characteristics. They also pointed out that the increased rate of cost conversations among primary care doctors may reflect the primary care specialty’s focus on whole person care, though they added that this result is “remarkable given the number of competing priorities in a typical primary care visit.”

As for the finding that cost conversations did not seem to impact medication choice, the editorialists suggested that this “might reflect unproductive conversations or competing factors in the decision. We also note that because most (79%) patients in the study were already taking an anticoagulant, clinical inertia may have proven more powerful than any conversation.”

Study limitations included that the general nature of the costs offered in the SDM tool “may have been sufficient to trigger cost conversations but in terms not individualized enough… to support those conversations”; the findings may not apply to individuals who would have opted out of the SDM4AFib trial; the findings may not be generalizable to non-U.S. clinical encounters or health systems; and the study does not assess conversation initiator, quality, length, and content.

  1. Use of a shared decision-making (SDM) tool, along with clinician factors such as gender, specialty, and experience, were associated with a greater likelihood of clinicians discussing the cost of anticoagulation therapy during interactions with patients with atrial fibrillation (AFib).

  2. While more patients who had cost conversations with their clinician reported cost as a factor in their treatment decision, those cost conversations were not associated with the choice of anticoagulation agent.

John McKenna, Associate Editor, BreakingMED™

Brito reported receiving grants from the Gordon and Betty Moore Foundation during the conduct of the study. Coauthors Kamath, Kunneman, and Shah reported grants from the National Institutes of Health (NIH) during the conduct of the study; Shah also reported receiving research support through Mayo Clinic from the Food and Drug Administration to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program, the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative, the Agency for Healthcare Research and Quality, the National Heart, Lung, and Blood Institute, the National Science Foundation, the Medical Device Innovation Consortium as part of the National Evaluation System for Health Technology, and the Patient Centered Outcomes Research Institute to develop a Clinical Data Research Network; coauthor Jackson reported research funding from NIH and Amgen, serving on the editorial board for Circulation, consulting fees from the American College of Cardiology and McKesson, Inc., and publishing royalties from UpToDate.

Ganguli and Thakore reported receiving grants from the Robert Wood Johnson Foundation outside the submitted work, and Ganguli is an associate editor of JAMA Network Open.

Cat ID: 913

Topic ID: 74,913,730,913,192,925