Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF): A Trial Providing Out-of-Pocket Costs for Heart Failure Medications during Clinical Encounters.

BACKGROUND: Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) often entails substantial out-of-pocket costs that can vary appreciably between patients. This has raised concerns regarding financial toxicity, equity, and adherence to medical therapy. In spite of these concerns, cost discussions in the HFrEF population appear to be rare, partly because out-of-pocket costs are generally unavailable during clinical encounters. In this trial, out-of-pocket cost information is given to patients and clinicians during outpatient encounters with the aim to assess the impact of providing this information on medication discussions and decisions. HYPOTHESIS: Cost-informed decision-making will be facilitated by providing access to patient-specific out-of-pocket cost estimates at the time of clinical encounter. DESIGN: Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF) is a multicenter trial based at Emory Healthcare and University of Colorado Health. Adapting an existing patient activation tool from the EPIC-HF trial, patients and clinicians are presented a checklist with medications approved for treatment of HFrEF with or without patient-specific out-of-pocket costs (obtained from a financial navigation firm). Clinical encounters are audio-recorded, and patients are surveyed about their experience. The trial utilizes a stepped-wedge cluster randomized design, allowing for each site to enroll control and intervention group patients while minimizing contamination of the control arm. DISCUSSION: This trial will elucidate the potential impact of robust cost disclosure efforts and key information regarding patient and clinician perspectives related to cost and cost communication. It also will reveal important challenges associated with providing out-of-pocket costs for medications during clinical encounters. Acquiring medication costs for this trial requires an involved process and outsourcing of work. In addition, costs may change throughout the year, raising questions regarding what specific information is most valuable. These data will represent an important step towards understanding the role of integrating cost discussions into heart failure care. GOV IDENTIFIER: NCT04793880.

Comparing a Data Entry Tool to Provider Insights Alone for Assessment of COVID-19 Hospitalization Risk: Pilot Matched Cohort Comparison Study.

BACKGROUND: In March 2020, the World Health Organization declared COVID-19 a global pandemic, necessitating an understanding of factors influencing severe disease outcomes. High COVID-19 hospitalization rates underscore the need for robust risk prediction tools to determine estimated risk for future hospitalization for outpatients with COVID-19. We introduced the "COVID-19 Risk Tier Assessment Tool" (CRTAT), designed to enhance clinical decision-making for outpatients. OBJECTIVE: We investigated whether CRTAT offers more accurate risk tier assignments (RTAs) than medical provider insights alone. METHODS: We assessed COVID-19-positive patients enrolled at Emory Healthcare's Virtual Outpatient Management Clinic (VOMC)-a telemedicine monitoring program, from May 27 through August 24, 2020-who were not hospitalized at the time of enrollment. The primary analysis included patients from this program, who were later hospitalized due to COVID-19. We retroactively formed an age-, gender-, and risk factor-matched group of nonhospitalized patients for comparison. Data extracted from clinical notes were entered into CRTAT. We used descriptive statistics to compare RTAs reported by algorithm-trained health care providers and those produced by CRTAT. RESULTS: Our patients were primarily younger than 60 years (67% hospitalized and 71% nonhospitalized). Moderate risk factors were prevalent (hospitalized group: 1 among 11, 52% patients; 2 among 2, 10% patients; and ≥3 among 4, 19% patients; nonhospitalized group: 1 among 11, 52% patients, 2 among 5, 24% patients, and ≥3 among 4, 19% patients). High risk factors were prevalent in approximately 45% (n=19) of the sample (hospitalized group: 11, 52% patients; nonhospitalized: 8, 38% patients). Approximately 83% (n=35) of the sample reported nonspecific symptoms, and the symptoms were generally mild (hospitalized: 12, 57% patients; nonhospitalized: 14, 67% patients). Most patient visits were seen within the first 1-6 days of their illness (n=19, 45%) with symptoms reported as stable over this period (hospitalized: 7, 70% patients; nonhospitalized: 3, 33% patients). Of 42 matched patients (hospitalized: n=21; nonhospitalized: n=21), 26 had identical RTAs and 16 had discrepancies between VOMC providers and CRTAT. Elements that led to different RTAs were as follows: (1) the provider "missed" comorbidity (n=6), (2) the provider noted comorbidity but undercoded risk (n=10), and (3) the provider miscoded symptom severity and course (n=7). CONCLUSIONS: CRTAT, a point-of-care data entry tool, more accurately categorized patients into risk tiers (particularly those hospitalized), underscored by its ability to identify critical factors in patient history and clinical status. Clinical decision-making regarding patient management, resource allocation, and treatment plans could be enhanced by using similar risk assessment data entry tools for other disease states, such as influenza and community-acquired pneumonia. The COVID-19 pandemic has accelerated the adoption of telemedicine, enabling remote patient tools such as CRTAT. Future research should explore the long-term impact of outpatient clinical risk assessment tools and their contribution to better patient care.

Interpersonal Primary Care Continuity for Chronic Conditions Is Associated with Fewer Hospitalizations and Emergency Department Visits Among Medicaid Enrollees.

BACKGROUND: Interpersonal primary care continuity or chronic condition continuity (CCC) is associated with improved health outcomes. Ambulatory care-sensitive conditions (ACSC) are best managed in a primary care setting, and chronic ACSC (CACSC) require management over time. However, current measures do not measure continuity for specific conditions or the impact of continuity for chronic conditions on health outcomes. The purpose of this study was to design a novel measure of CCC for CACSC in primary care and determine its association with health care utilization. METHODS: We conducted a cross-sectional analysis of continuously enrolled, nondual eligible adult Medicaid enrollees with a diagnosis of a CACSC using 2009 Medicaid Analytic eXtract files from 26 states. We conducted adjusted and unadjusted logistic regression models of the relationship between patient continuity status and emergency department (ED) visits and hospitalizations. Models were adjusted for age, sex, race/ethnicity, comorbidity, and rurality. We defined CCC for CACSC as at least 2 outpatient visits with any primary care physician for a CACSC in the year, and (2) more than 50% of outpatient CACSC visits with a single PCP. RESULTS: There were 2,674,587 enrollees with CACSC and 36.3% had CCC for CACSC visits. In fully adjusted models, enrollees with CCC were 28% less likely to have ED visits compared with those without CCC (aOR = 0.71, 95% CI = 0.71 - 0.72) and were 67% less likely to have hospitalization than those without CCC (aOR = 0.33, 95% CI = 0.32-0.33). CONCLUSIONS: CCC for CACSCs was associated with fewer ED visits and hospitalizations in a nationally representative sample of Medicaid enrollees.

Financial Considerations After a Fully-Virtual Interview Season: A CERA Study of Family Medicine Residency Program Directors.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic led to the institution of virtual interviewing for nearly all family medicine residency programs in 2020 and 2021. This paradigm shift challenged the perspectives of family medicine program directors across the United States, in part because of the financial impact on the operations of many residency programs. We sought to investigate program directors' opinions on the 2020-2021 interview season, as well whether future interview season planning would be influenced by the financial outcomes of this season. METHODS: We conducted a cross-sectional survey, as part of the fall 2021 CERA Program Director omnibus online survey. Family medicine program directors were invited by email to participate. We conducted multivariate logistic regression of the likelihood of supporting a fully-virtual interviewing model. RESULTS: The module survey response rate was 41.7% (263/631); 91.3% of programs reported conducting a fully-virtual 2020-2021 interview season. Program directors who reported that the cost savings recouped from virtual versus in-person interviewing could be used for other residency operating costs (32.4%) were almost four times more likely to support moving to a fully-virtual interviewing model (odds ratio: 3.94, confidence interval: 1.69-9.18). When compared to a residency program's benefit from meeting and assessing applicants in person, applicants benefitting from less financial burden during a fully-virtual interview season was not seen by responding program directors as a significant reason to remain virtual. CONCLUSIONS: While family medicine residency program directors who recouped interview expenses during fully-virtual recruiting seasons are more likely to support ongoing, fully-virtual models, financial incentivization did not overall impact support for virtual interviewing among program directors with statistical significance.

Impact of Financial Considerations on Willingness to Take Sacubitril/Valsartan for Heart Failure.

Background Sacubitril/valsartan improves health outcomes for heart failure with reduced ejection fraction relative to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, but it carries higher out-of-pocket costs. Neither the impact of cost nor how to integrate cost into medical decisions is well studied. Methods and Results To evaluate the impact of out-of-pocket costs and a novel cost-priming intervention on willingness to take sacubitril/valsartan for heart failure with reduced ejection fraction, participants with self-reported heart disease were surveyed using the online Ipsos Knowledge Panel. Participants were presented with a modified decision aid for sacubitril/valsartan and then, in a 3×2 factorial design, randomly assigned to 1 of 3 cost conditions ($10, $50, or $100/month) and to a control group or cost-priming intervention, defined by being asked questions about their financial situation before learning about the benefits of sacubitril/valsartan. Of the 1013 participants included in the analysis, 85% of respondents were willing to take sacubitril/valsartan at $10, 62% at $50, and 33% at $100 (P<0.0001). In a multivariable logistic regression model, participants were more likely to take sacubitril/valsartan at $10 versus $100 (odds ratio [OR], 14.3 [95% CI, 9.4-21.8]) and $50 compared with $100 (OR, 3.6 [95% CI, 2.5-5.1]). Overall, participants in the cost-primed group were more willing to take sacubitril/valsartan than those not primed to consider their financial situation (63% versus 56%, P=0.04). There was no statistically significant interaction between cost conditions and cost priming. Perceived benefit of sacubitril/valsartan over angiotensin-converting enzyme inhibitors or angiotensin receptor blockers decreased as cost increased but did not vary by cost priming. Conclusions Commonly encountered out-of-pocket costs of sacubitril/valsartan may impact individuals' willingness to take the medication even when recommended by their physicians. Priming individuals to consider personal finances before learning about the drug increased willingness to take sacubitril/valsartan.

Cost Analysis of Developing, Implementing, and Evaluating a Multi-Disciplinary Teaching Kitchen.

INTRODUCTION: Teaching kitchens have emerged as strategies to deliver lifestyle medicine principles and practices. However, a better understanding of their implementation, delivery cost, and potential benefits are needed. This article provides a comprehensive analysis of the costs associated with the development, deployment, and evaluation of the Emory Healthy Kitchen Collaborative (EHKC) teaching kitchen clinical trial. METHODS: The actual number of hours spent and costs incurred to develop and deploy the EHKC teaching kitchen were recorded and broadly categorized into 1 of 4 areas: program development, course delivery, research, and optional enhancements. Costs of each item were assigned as fixed or variable, enabling calculation of the marginal per participant program cost. RESULTS: Total costs were US$123,898, with 3/4 incurred for program development, research, and optional enhancements. Delivery of the course alone (not including program development costs, research, or any optional enhancements) cost US$30,194. The total cost per participant for the course was US$755, with a marginal participant cost of US$141. CONCLUSION: Teaching kitchens represent viable options to deliver lifestyle medicine interventions. However, more research and cost analyses are needed to better understand the value teaching kitchens provide to determine if they are an effective and economical way to deliver lifestyle medicine.

Neighborhood-Level Redlining and Lending Bias Are Associated with Breast Cancer Mortality in a Large and Diverse Metropolitan Area.

BACKGROUND: Structural inequities have important implications for the health of marginalized groups. Neighborhood-level redlining and lending bias represent state-sponsored systems of segregation, potential drivers of adverse health outcomes. We sought to estimate the effect of redlining and lending bias on breast cancer mortality and explore differences by race. METHODS: Using Georgia Cancer Registry data, we included 4,943 non-Hispanic White (NHW) and 3,580 non-Hispanic Black (NHB) women with a first primary invasive breast cancer diagnosis in metro-Atlanta (2010-2014). Redlining and lending bias were derived for census tracts using the Home Mortgage Disclosure Act database. We calculated hazard ratios and 95% confidence intervals (CI) for the associations of redlining, lending bias on breast cancer mortality and estimated race-stratified associations. RESULTS: Overall, 20% of NHW and 80% of NHB women lived in redlined census tracts, and 60% of NHW and 26% of NHB women lived in census tracts with pronounced lending bias. Living in redlined census tracts was associated with a nearly 1.60-fold increase in breast cancer mortality (hazard ratio = 1.58; 95% CI, 1.37-1.82) while residing in areas with substantial lending bias reduced the hazard of breast cancer mortality (hazard ratio = 0.86; 95% CI, 0.75-0.99). Among NHB women living in redlined census tracts, we observed a slight increase in breast cancer mortality (hazard ratio = 1.13; 95% CI, 0.90-1.42); among NHW women the association was more pronounced (hazard ratio = 1.39; 95% CI, 1.09-1.78). CONCLUSIONS: These findings underscore the role of ecologic measures of structural racism on cancer outcomes. IMPACT: Place-based measures are important contributors to health outcomes, an important unexplored area that offers potential interventions to address disparities.

Show Me the Money: Patients' Perspectives on a Decision Aid for Sacubitril/Valsartan Addressing Out-of-Pocket Cost.

BACKGROUND: Out-of-pocket medication costs for patients who have heart failure with reduced ejection fraction may be an important part of shared decision-making, but cost has generally been excluded from clinical discussions. This study reports patients' perspectives on a decision aid for sacubitril/valsartan that explicitly addresses out-of-pocket costs. METHODS: Structured, in-depth interviews were conducted with 20 patients with heart failure with reduced ejection fraction from 2 medical centers to elicit their views on a publicly available decision aid for sacubitril/valsartan that explicitly incorporates considerations related to out-of-pocket costs. Qualitative descriptive analysis was conducted. RESULTS: Key themes identified were general enthusiasm for decision aids for medication decisions, openness on the part of patients to incorporation of cost into decision-making and the decision aid, requests for greater specificity regarding patient-specific cost, and challenges communicating evidence of benefit in a way that allows patients to make cost-benefit analyses for themselves. Patients also raised questions regarding logistical challenges of incorporating a decision aid into the normal clinical and decision-making workflow. CONCLUSIONS: Patients were receptive to the inclusion of out-of-pocket cost as relevant in a decision aid for sacubitril/valsartan. Key challenges to effective integration of cost in these decisions include developing mechanisms for acquiring reliable patient-specific cost estimates and addressing patients' difficulties (and sometimes skepticism) applying trial evidence to their own situation. In addition, implementation strategies are important to develop to facilitate decision aid integration for routine medical decisions into clinic workflow.

Heart Failure and Shared Decision-Making: Patients Open to Medication-Related Cost Discussions.

BACKGROUND: Discussions of medication costs between patients and clinicians are infrequent and often suboptimal. In the context of recently introduced drugs that are effective but expensive, patients with heart failure with reduced ejection fraction provide an ideal population to understand the perspectives of patients with chronic illness on medication cost and cost discussions. METHODS: To explore patients' perspectives on discussing out-of-pocket medication costs with clinicians, 49 adults, aged 44 to 70 years, with heart failure with reduced ejection fraction were recruited from outpatient heart failure clinics. Descriptive qualitative analysis was performed on open-ended text data. RESULTS: Participants who had prior medication-related cost discussions described their experience as generally positive, but about half of the participants had never had a cost discussion with their clinician. Most participants were open to cost discussions with clinicians and preferred that the clinician initiate discussions regarding medication cost. Importantly, these preferences held constant across reported levels of financial burden. CONCLUSIONS: These data suggest a substantial willingness on the part of patients with heart failure with reduced ejection fraction to incorporate cost discussions into their care and identify important aspects of these discussions for clinicians to consider when engaging in conversations where cost is relevant. Improving understanding about how to integrate patient preferences regarding cost discussions into clinical encounters is an important priority for advancing patient-centered care.

Non-hospitalized Adults with COVID-19 Differ Noticeably from Hospitalized Adults in Their Demographic, Clinical, and Social Characteristics.

The characteristics of patients with coronavirus disease 2019 (COVID-19) have primarily been described in hospitalized adults. Characterization of COVID-19 in ambulatory care is needed for a better understanding of its evolving epidemiology. Our aim is to provide a description of the demographics, comorbidities, clinical presentation, and social factors in confirmed SARS-CoV-2-positive non-hospitalized adults. We conducted a retrospective medical record review of 208 confirmed SARS-CoV-2-positive patients treated in a COVID-19 virtual outpatient management clinic established in an academic health system in Georgia. The mean age was 47.8 (range 21-88) and 69.2% were female. By race/ethnicity, 49.5% were non-Hispanic African American, 25.5% other/unknown, 22.6% non-Hispanic white, and 2.4% Hispanic. Nearly 70% had at least one preexisting medical condition. The most common presenting symptoms were cough (75.5%), loss of smell or taste (63%), headache (62%), and body aches (54.3%). Physician or advanced practice provider assessed symptom severity ranged from 51.9% mild, 30.3% moderate, and 1.4% severe. Only eight reported limitations to home care (3.8%), 55.3% had a caregiver available, and 93.3% reported initiating self-isolation. Care needs were met for 83.2%. Our results suggest the demographic and clinical characteristics of COVID-19 illness in non-hospitalized adults differ considerably from hospitalized patients and warrant greater awareness of risk among younger and healthier individuals and consideration of testing and recommending self-isolation for a wider spectrum of clinical symptoms by clinicians. Social factors may also influence the efficacy of preventive strategies and allocation of resources toward the SARS-CoV-2 pandemic.

Primary Care Comprehensiveness and Care Coordination in Robust Specialist Networks Results in Lower Emergency Department Utilization: A Network Analysis of Medicaid Physician Networks.

Background: Care coordination is an essential and difficult to measure function of primary care. Objective: Our objective was to assess the impact of network characteristics in primary/specialty physician networks on emergency department (ED) visits for patients with chronic ambulatory care sensitive conditions (ACSCs). Subjects and Measures: This cross-sectional social network analysis of primary care and specialty physicians caring for adult Medicaid beneficiaries with ACSCs was conducted using 2009 Texas Medicaid Analytic eXtract (MAX) files. Network characteristic measures were the main exposure variables. A negative binomial regression model analyzed the impact of network characteristics on the ED visits per patient in the panel. Results: There were 42 493 ACSC patients assigned to 5687 primary care physicians (PCPs) connected to 11 660 specialist physicians. PCPs whose continuity patients did not visit a specialist had 86% fewer ED visits per patient in their panel, compared with PCPs whose patients saw specialists. Among PCPs connected to specialists in the network, those with a higher number of specialist collaborators and those with a high degree of centrality had lower patient panel ED rates. Conclusions: PCPs providing comprehensive care (ie, without specialist consultation) for their patients with chronic ACSCs had lower ED utilization rates than those coordinating care with specialists. PCPs with robust specialty networks and a high degree of centrality in the network also had lower ED utilization. The right fit between comprehensiveness of primary care, care coordination, and adequate capacity of specialty availability in physician networks is needed to drive outcomes.

Disconnected: a survey of users and nonusers of telehealth and their use of primary care.

OBJECTIVE: The study sought to assess awareness, perceptions, and value of telehealth in primary care from the perspective of patients. MATERIALS AND METHODS: We conducted a cross-sectional, Web-based survey of adults with access to telehealth services who visited healthcare providers for any of the 20 most-commonly seen diagnoses during telehealth visits. Three groups were studied: registered users (RUs) of telehealth had completed a LiveHealth Online (a health plan telehealth service provider) visit, registered nonusers (RNUs) registered for LiveHealth Online but had not conducted a visit, and nonregistered nonusers (NRNUs) completed neither step. RESULTS: Of 32 831 patients invited, 3219 (9.8%) responded and 766 met eligibility criteria and completed surveys: 390 (51%) RUs, 117 (15%) RNUs, and 259 (34%) NRNUs. RUs were least likely to have a primary care usual source of care (65.6% vs 78.6% for RNUs vs 80.0% for NRNUs; P < .001). Nearly half (46.8%) of RUs were unable to get an appointment with their doctor, and 34.8% indicated that their doctor's office was closed. Among the 3 groups, RUs were most likely to be employed (89.5% vs 88.9% vs 82.2%; P = .007), have post-high school education (94.4% vs 93.2% vs 86.5%; P = .003), and live in urban areas (81.0% vs 69.2% vs 76.0%; P = .021). CONCLUSIONS: Telehealth users reported that they relied on live video for enhanced access and were less connected to primary care than nonusers were. Telehealth may expand service access but risks further fragmentation of care and undermining of the primary care function absent better coordination and information sharing with usual sources of patients' care.

Core Principles to Improve Primary Care Quality Management.

Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine. Increasingly, its contribution to achieving the Quadruple Aim is under close examination, especially in the domain of primary care services, where the burden of measurement is heaviest. This article assesses the state of quality management in primary care in the United States, particularly the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, in comparative perspective, drawing lessons from the Quality and Outcomes Framework in the United Kingdom. The health care delivery function specific to primary care is pivotal to crossing the quality chasm, yet prior efforts to improve the quality of this function have failed more often than succeeded. These failures are the result of quality programs unguided by core principles of primary care. Quality management in primary care requires a more disciplined approach, adherent to 4 foundational principles: optimizing holistic patient and population health; harnessing the Quadruple Aim as a dynamic whole; applying measurements as tools for quality, not outcomes of quality; and prioritizing therapeutic relationships. These principles serve as the foundation for a bridge to high-functioning primary care that will lead American health care closer to the Quadruple Aim.

Rural Family Physicians Are Twice as Likely to Use Telehealth as Urban Family Physicians.

BACKGROUND: Telehealth has the potential to reduce health inequities and improve health outcomes among rural populations through increased access to physicians, specialists, and reduced travel time for patients. INTRODUCTION: Although rural telehealth services have expanded in several specialized areas, little is known about the attitudes, beliefs, and uptake of telehealth use in rural American primary care. This study characterizes the differences between rural and urban family physicians (FPs), their perceptions of telehealth use, and barriers to further adoption. MATERIALS AND METHODS: Nationally representative randomly sampled survey of 5,000 FPs. RESULTS: Among the 31.3% of survey recipients who completed the survey, 83% practiced in urban areas and 17% in rural locations. Rural FPs were twice as likely to use telehealth as urban FPs (22% vs. 10%). Logistic regressions showed rural FPs had greater odds of reporting telehealth use to connect their patients to specialists and to care for their patients. Rural FPs were less likely to identify liability concerns as a barrier to using telehealth. DISCUSSION: Telemedicine allows rural patients to see specialists without leaving their communities and permits rural FPs to take advantage of specialist expertise, expand their scope of practice, and reduce the feeling of isolation experienced by rural physicians. CONCLUSION: Efforts to raise awareness of current payment policies for telehealth services, addressing the limitations of current reimbursement policies and state regulations, and creating new avenues for telehealth reimbursement and technological investments are critical to increasing primary care physician use of telehealth services.

Physician Training in Cancer Prevention and Control: A Population Health Imperative.

Cancer is the second leading cause of morbidity and mortality in the U.S. Although reducing the number of new cancer cases is a national health goal, the continuing growth of the older adult population ensures that the burden of cancer will increase. Despite documentation of the shortage of oncologists to meet the growing need, relatively limited attention has been focused on increasing the physician workforce trained in the prevention and control of cancer. The existing physician workforce with such specialized training in cancer prevention and control is small, aging, increasing at a low rate, and likely to decrease because of an imbalance between retiring physicians and new entrants. This commentary addresses the imperative for increasing the number of physicians trained in preventive medicine with a specialization in cancer prevention and control by first providing a brief overview of U.S. cancer morbidity and mortality, then describing the status of, and trends in, physician training in cancer prevention and control, and concluding by suggesting opportunities for bolstering physician training in cancer prevention and control.

Analysis of 2011 physician assistant education debt load.

This study seeks to investigate how physician assistants (PAs) finance their education and to characterize the educational debt of PA students. Data from the 2011 American Academy of PAs (AAPA)-Physician Assistant Education Association Graduating Student Survey were used to explore the educational debt of PA students. The median total educational debt of a PA student graduating in 2011 was $80,000. Little financial assistance, other than student loans, is available to PA students. Eighty-five percent of PA students report owing some PA education debt amount, with 23% owing at least $100,000. This study provides a baseline look at PA student debt loads as a starting point for more detailed and robust research into new graduate specialty choices and PA career migration into other specialties. Further research is needed to explore the effect of student debt on students' specialty choices.