Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians

JAMA Network Open, vol. 4, pp. e2116009

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.

Authors 54

1. Celia C. Kamath

   Mayo Clinic

   Affiliation as printed

   Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

   Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota

2. Rachel E. Giblon

   Mayo Clinic

   Affiliation as printed

   Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota

   Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota

3. Marlene Kunneman Aachen Department of Biomedical Data Sciences

   Mayo Clinic · Leiden University Medical Center

   Affiliation as printed

   Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands

   Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

4. Megan E. Branda

   Mayo Clinic · Colorado School of Public Health · University of Colorado Anschutz · University of Colorado Denver

   Affiliation as printed

   Colorado School of Public Health, Anschutz Medical Campus, University of Colorado, Denver, Aurora

   Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

5. Ian G Hargraves

   Mayo Clinic

   Affiliation as printed

   Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

6. Angela L. Sivly

   Mayo Clinic

   Affiliation as printed

   Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

7. Fernanda Bellolio

   Mayo Clinic

   Affiliation as printed

   Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota

8. Elizabeth Anne Jackson

   University of Alabama at Birmingham

   Affiliation as printed

   Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham

9. Haeshik S. Gorr
   Affiliation as printed

   Division of General Internal Medicine, Hennepin Health, Minneapolis, Minnesota

10. Victor D. Torres Roldan

    Mayo Clinic

    Affiliation as printed

    Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

    Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota

11. Gabriella Spencer-Bonilla

    Stanford Medicine · Stanford University

    Affiliation as printed

    Stanford Internal Medicine Residency Program, California

12. Nilay D. Shah

    Mayo Clinic

    Affiliation as printed

    Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota

13. Peter A. Noseworthy

    Mayo Clinic

    Affiliation as printed

    Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota

    Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota

14. Víctor M. Montori

    Mayo Clinic

    Affiliation as printed

    Department of Endocrinology, Mayo Clinic, Rochester, Minnesota

    Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

15. Juan Pablo Brito corresponding

    Mayo Clinic

    Affiliation as printed

    Department of Endocrinology, Mayo Clinic, Rochester, Minnesota

    Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota

16. Alexander Haffke
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

17. Amy Stier
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

18. Anjali D. Thota
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

19. Annie LeBlanc
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

20. Benjamin Simpson
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

21. Claudia Liz Zeballos-Palacios
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

22. Derek E. Vanmeter
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

23. Emma Behnken
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

24. Erik P. Hess
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

25. Henry H. Ting
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

26. Joel Anderson
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

27. Jonathan Inselman
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

28. Jule Muegge
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

29. Marc Olive
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

30. Mark Linzer
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

31. Miamoua Vang
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

32. Michael J. Ferrara
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

33. Mike Wambua
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

34. Paige W. Organick
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

35. Renee Cabalka
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

36. Sara Poplau
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

37. Takeki Suzuki
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

38. Carol Abullarade
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

39. Lisa Anne Harvey
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

40. Shelly Keune
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

41. Timothy D. Smith
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

42. Shannon W. Stephens
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

43. Bryan R. Barksdale
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

44. Roma Peters
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

45. Memrie Price
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

46. Connie Watson
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

47. Douglas A. Wolfe
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

48. Gordon Henry Guyatt
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

49. Brian R Haynes
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

50. GEORGE A. TOMLINSON
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

51. Paul R. Daniels
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

52. Bernard John Gersh
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

53. Thomas M. Jaeger
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators

54. Robert D. McBane
    Affiliation as printed

    for the Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators