Impact of Cost Conversations During Clinical Encounters Aided by Shared Decision-Making Tools on Medication Adherence.

Objective: To investigate the impact of cost conversations occurring with or without the use of encounter shared decision-making (SDM) tools in medication adherence. Patients and Methods: Using a coding scheme that included the occurrence and characteristics of cost conversation, we analyzed a randomly selected sample of 169 video recordings of clinical encounters. These videos were obtained during the conduct of practice-based randomized clinical trials comparing care with and without SDM tools for patients with diabetes, osteoporosis, and depression. Medication adherence was described in 2 ways: as a binary (yes/no) outcome, in which the patient met at least 80% adherence, or as a continuous variable, which was the percent of days that the patient adhered to their medication. The secondary analysis took place in 2018 from trials that ran between 2007 and 2015. Results: Most patients were White (155, 93.4%), educated (104, 63.4% completed college), middle-aged (mean age, 58 years), female (104, 61.5%), and from diabetes (86, 50.9%), depression (43, 25.4%), and osteoporosis (40, 23.7%) trials. Cost conversations occurred in 119 clinical encounters (70%) and were more frequent in those encounters in which SDM tools were used (P=.03). Furthermore, 97 (57.4%) of the participants reported more than 80% medication adherence and 70.3±29.34 percentage of days with adherent medication of 70 days. In the multiple regression model, the only factor associated with adherence (binary or continuous) was the condition of the trial in which people participated. For the participants who had cost conversations, the use of an SDM tool, their sex, the nature of cost conversation (direct or indirect), the nature of cost concerns (treatment or patient issue), and the clinician-offered strategies (yes or no) were not associated with adherence. Conclusion: In this videographic analysis of SDM practice-based clinical trials, cost conversations were not associated with the general measures of medication adherence. Future studies should assess whether a tailored cost conversation intervention would impact the cost-related nonadherence among patients.

Neighborhood-Level Socioeconomic Deprivation, Rurality, and Long-Term Outcomes of Patients Undergoing Total Joint Arthroplasty: Analysis from a Large, Tertiary Care Hospital.

Objective: To assess the impact of neighborhood-level socioeconomic status factors (area deprivation index [ADI] and rural classification) and their interaction with individual-level socioeconomic status (education-level) on long-term outcomes following total joint arthroplasty (TJA) surgery. Patients and Methods: This was a cohort study of 46,828 TJA surgeries performed on patients at a tertiary care hospital between January 1, 2000 and December 31, 2019. Cox proportional hazards models were used to examine the association between ADI and rurality and their interaction with individual-level education on the risk of periprosthetic joint infections, revision surgery, and mortality. Results: At the time of surgery, 2589 (6%) patients lived in the most deprived neighborhoods (ADI quintile >80%) and 10,728 (23%) lived in small isolated rural towns. Patients from the most deprived neighborhoods were more likely to experience revision surgery (hazard ratio, [HR], 1.39; 95% CI, 1.10-1.76) and mortality (HR, 1.24; 95% CI, 1.09-1.42). Patients from small rural towns were also more likely to undergo revision surgery (HR, 1.14; 95% CI, 1.01-1.28). The mortality risk was 13%, 18%, and 24% higher for patients in the 3 highest ADI quintiles than those from the lowest quintile. Education gradient was more notable in the least deprived neighborhoods than in the most deprived neighborhoods. Conclusion: Neighborhood disadvantage and rurality are negatively associated with the risk of revision surgery and both independently and in interaction with individual-level education with the risk of mortality. There is a need for population-level health interventions to mitigate area-based socioeconomic disadvantages in TJA.

Association of Rurality and Neighborhood Level Socioeconomic Deprivation with Perioperative Health Status in Total Joint Arthroplasty Patients: Analysis from a Large, Tertiary Care Hospital.

BACKGROUND: Individual socioeconomic status (SES) is associated with disparities in access to care and worse outcomes in total joint arthroplasty (TJA). Neighborhood-level SES measures are sometimes used as a proxy for individual-level SES, but the validity of this approach is unknown. We examined neighborhood level SES and rurality on perioperative health status in TJA. METHODS: The study population comprised 46,828 TJA surgeries performed at a tertiary care hospital. Community area deprivation index (ADI) was derived from the 2015 American Census Survey. Logistic regression was used to examine perioperative characteristics by ADI and rurality. RESULTS: Compared to patients from the least deprived neighborhoods, patients from the most deprived neighborhoods were likely to be female (odds ratioOR 1.46, 95% confidence interval CI: 1.33-1.61), non-white (OR 1.36, 95% CI: 1.13-1.64), with education high school or less (OR 4.85, 95% CI: 4.35-5.41), be current smokers (OR 2.20, 95% CI: 1.61-2.49), have BMI>30 kg/m2 (OR 1.43, 95% CI: 1.30-1.57), more limitation on instrumental activities of daily living (OR 1.75, 95% CI: 1.55-1.97) and American Society of Anesthesiologists (ASA) score > II (OR 2.0, 95% CI: 1.11-1.37). There was a progressive association between the degree of area level deprivation with preexisting comorbidities. Patients from rural communities were more likely to be male, white, have body mass index (BMI)>30 kg/m2 and lower education levels. However, rurality was either not associated or negatively associated with comorbidities. CONCLUSION: TJA patients from lower SES neighborhoods have worse behavioral risk factors and higher comorbidity burden than patients from higher SES neighborhoods. Patients from rural communities have worse behavioral risk factors but not comorbidities.

Impact of Cost Conversation on Decision-Making Outcomes.

OBJECTIVE: To understand the impact of cost conversations on the following decision-making outcomes: patients' knowledge about their conditions and treatment options, decisional conflict, and patient involvement. PATIENTS AND METHODS: In 2020 we performed a secondary analysis of a randomly selected set of 220 video recordings of clinical encounters from trials run between 2007 and 2015. Videos were obtained from eight practice-based randomized trials and one pre-post-prospective study comparing care with and without shared decision-making (SDM) tools. RESULTS: The majority of trial participants were female (61%) and White (86%), with a mean age of 56, some college education (68%), and an income greater than or equal to $40,000 per year (75%), and who did not participate in an encounter aided by an SDM tool (52%). Cost conversations occurred in 106 encounters (48%). In encounters with SDM tools, having a cost conversation lead to lower uncertainty scores (2.1 vs 2.6, P=.02), and higher knowledge (0.7 vs 0.6, P=.04) and patient involvement scores (20 vs 15.7, P=.009) than in encounters using SDM tools where cost conversations did not occur. In a multivariate model, we found slightly worse decisional conflict scores when patients started cost conversations as opposed to when the clinicians started cost conversations. Furthermore, we found higher levels of knowledge when conversations included indirect versus direct cost issues. CONCLUSION: Cost conversations have a minimal but favorable impact on decision-making outcomes in clinical encounters, particularly when they occurred in encounters aided by an SDM tool that raises cost as an issue.

Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial.

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.

Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies.

INTRODUCTION: Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care. METHODS: Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory. RESULTS: Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD - 3.86; 95% CI - 7.2 to - 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS. DISCUSSION: Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care. PROSPERO REGISTRATION NUMBER: CRD42018102441.

Using Shared Decision-Making Tools and Patient-Clinician Conversations About Costs.

OBJECTIVE: To determine how shared decision-making (SDM) tools used during clinical encounters that raise cost as an issue impact the incidence of cost conversations between patients and clinicians. PATIENTS AND METHODS: A randomly selected set of 220 video recordings of clinical encounters were analyzed. Videos were obtained from eight practice-based randomized clinical trials and one quasi-randomized clinical trial (pre- and post-) comparing care with and without SDM tools. The secondary analysis took place in 2018 from trials ran between 2007 and 2015. RESULTS: Most patient participants were white (85%), educated (38% completed college), middle-aged (mean age 56 years), and female (61%). There were 105 encounters with and 115 without the SDM tool. Encounters with SDM tools were more likely to include both general cost conversations (62% vs 36%, odds ratio [OR]: 9.6; 95% CI: 4 to 26) as well as conversations on medication costs specifically (89% vs 51%, P=.01). However, clinicians using SDM tools were less likely to address cost issues during the encounter (37% vs 51%, P=.04). Encounters with patients with less than a college degree were also associated with a higher incidence of cost conversations. CONCLUSION: Using SDM tools that raise cost as an issue increased the occurrence of cost conversations but was less likely to address cost issues or offer potential solutions to patients' cost concerns. This result suggests that SDM tools used during the consultation can trigger cost conversations but are insufficient to support them.

Developing an Educational Intervention to Address Financial Hardship in Cancer Patients.

OBJECTIVE: To develop an educational intervention to empower patients to manage their financial health better. PARTICIPANTS AND METHODS: This study was conducted from September 1, 2017, to January 31, 2019. Focus groups were held with social workers, case managers, and patient financial service staff and interviews were conducted with patients and caregivers to inform the content, delivery format, and timing of an intervention for mitigating financial hardship from treatment (phase 1). Based on qualitative data, theories of adult learning, and a review of the literature, we created an educational presentation to be delivered in a classroom setting. Two patient focus groups were then held for feedback on the presentation (phase 2). RESULTS: In phase 1, both patients and allied health care staff providers believed that an educational intervention about financial aspects of care early during treatment would help them cope and plan better. Participants' suggestions for the intervention's content included billing information, insurance, authorization processes, employment policies related to health care and disability benefits, and alternative financial resources. Based on these suggestions, a preliminary educational presentation was developed with 3 main themes: insurance issues, employment issues, and financial health. Phase 2 focus group participants suggested refinement of the presentation, including targeting specific groups, adding graphics, and more information about resources. CONCLUSION: Our study provides the basis for a patient-centered education module for emotional, instrumental, and informational support for financial distress for use in a clinical setting.

Implementation strategies for interventions to improve the management of chronic kidney disease (CKD) by primary care clinicians: protocol for a systematic review.

INTRODUCTION: There is a considerable implementation gap in managing early stage chronic kidney disease (CKD) in primary care despite the high prevalence and risk for increased morbidity and mortality associated with CKD. This systematic review aims to synthesise the evidence of efficacy of implementation interventions aimed at primary care practitioners (PCPs) to improve CKD identification and management. We further aim to describe the interventions' behavioural change components. METHODS AND ANALYSIS: We will conduct a systematic review of studies from 2000 to October 2017 that evaluate implementation interventions targeting PCPs and which include at least one clinically meaningful CKD outcome. We will search several electronic data bases and conduct reference mining of related systematic reviews and publications. An interdisciplinary team will independently and in duplicate, screen publications, extract data and assess the risk of bias. Clinical outcomes will include all clinically meaningful medical management outcomes relevant to CKD management in primary care such as blood pressure, chronic heart disease and diabetes target achievements. Quantitative evidence synthesis will be performed, where possible. Planned subgroup analyses include by (1) study design, (2) length of follow-up, (3) type of intervention, (4) type of implementation strategy, (5) whether a behavioural or implementation theory was used to guide study, (6) baseline CKD severity, (7) patient minority status, (8) study location and (9) academic setting or not. ETHICS AND DISSEMINATION: Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will inform a future trial of an intervention to promote uptake of CKD diagnosis and treatment guidelines in our primary care setting and the development of complementary tools to support its successful adoption and implementation. We will publish our findings in a peer-reviewed journal and develop accessible summaries of the results. PROSPERO REGISTRATION NUMBER: CRD42018102441.

Systematic reviewers commonly contact study authors but do so with limited rigor.

OBJECTIVES: Author contact can enhance the quality of systematic reviews. We conducted a systematic review of the practice of author contact in recently published systematic reviews to characterize its prevalence, quality, and results. STUDY DESIGN AND SETTING: Eligible studies were systematic reviews of efficacy published in 2005-2006 in the 25 journals with the highest impact factor publishing systematic reviews in clinical medicine and the Cochrane Library, identified by searching MEDLINE, EMBASE, and the Cochrane Library. Two researchers determined whether and why reviewers contacted authors. To assess the accuracy of the abstracted data, we surveyed reviewers by e-mail. RESULTS: Forty-six (50%) of the 93 eligible systematic reviews published in top journals and 46 (85%) of the 54 eligible Cochrane reviews reported contacting authors of eligible studies. Requests were made most commonly for missing information: 40 (76%) clinical medicine reviews and 45 (98%) Cochrane reviews. One hundred and nine of 147 (74%) reviewers responded to the survey, and reported a higher rate of author contact than apparent from the published record. CONCLUSION: Although common, author contact is not a universal feature of systematic reviews published in top journals and the Cochrane Library. The conduct and reporting of author contact purpose, procedures, and results require improvement.

Clinical review: behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials.

CONTEXT: The efficacy of lifestyle interventions to encourage healthy lifestyle behaviors to prevent pediatric obesity remains unclear. OBJECTIVE: Our objective was to summarize evidence on the efficacy of interventions aimed at changing lifestyle behaviors (increased physical activity, decreased sedentary activity, increased healthy dietary habits, and decreased unhealthy dietary habits) to prevent obesity. DATA SOURCES: Data sources included librarian-designed searches of nine electronic databases, references from included studies and reviews (from inception until February 2006), and content expert recommendations. STUDY SELECTION: Eligible studies were randomized trials enrolling children and adolescents assessing the impact of interventions on both lifestyle behaviors and body mass index (BMI). DATA EXTRACTION: Two reviewers independently abstracted data on methodological quality, study characteristics, intervention components, and treatment effects. DATA ANALYSIS: We conducted random-effects metaanalyses, quantified inconsistency using I(2), and conducted planned subgroup analyses for each examined outcome. DATA SYNTHESIS: Regarding target behaviors, the pooled effect size for physical activity (22 comparisons; n = 9891 participants) was 0.12 [95% confidence interval (CI) = 0.04-0.20; I(2) = 63%], for sedentary activity (14 comparisons; n = 3003) was -0.29, (CI = -0.35 to -0.22; I(2) = 0%), for healthy dietary habits (14 comparisons, n = 5468) was 0.00 (CI = -0.20; 0.20; I(2) = 83%), and for unhealthy dietary habits (23 comparisons, n = 9578) was -0.20 (CI = -0.31 to -0.09; I(2) = 34%). The effect of these interventions on BMI (43 comparisons, n = 32,003) was trivial (-0.02; CI = -0.06-0.02; I(2) = 17%) compared with control. Trials with interventions lasting more than 6 months (vs. shorter trials) and trials with postintervention outcomes (vs. in-treatment outcomes) yielded marginally larger effects. CONCLUSION: Pediatric obesity prevention programs caused small changes in target behaviors and no significant effect on BMI compared with control. Trials evaluating promising interventions applied over a long period, using responsive outcomes, with longer measurement timeframes are urgently needed.

Economic and clinical outcomes of a physician-led continuous quality improvement intervention in the delivery of percutaneous coronary intervention.

OBJECTIVE: To compare clinical and economic outcomes associated with percutaneous coronary intervention (PCI) in cohorts before and after continuous quality improvement (CQI) was instituted. STUDY DESIGN: Observational study. METHODS: Clinical, angiographic, procedural, and outcome data on 1441 pre-CQI and 1760 post-CQI PCIs (performed in 1997 and 1998, respectively) were derived from an institutional PCI registry. Administrative data were used to estimate total procedural and postprocedural costs and length of stay (LOS). Logistic and generalized linear modeling was used to adjust in-hospital clinical and economic outcomes, respectively, for differences in patient characteristics. RESULTS: The 2 cohorts were similar in terms of age, sex, and rate of diabetes. Post-CQI patients more often received intracoronary stents, had urgent PCIs, had a history of prior PCI, and received glycoprotein IIb/IIIa inhibitors. Procedural success without in-hospital complications occurred in 90% of both cohorts and did not differ statistically in adjusted analyses. Compared with patients treated pre-CQI, those treated post-CQI had a reduced adjusted odds ratio for in-hospital death or any myocardial infarction (odds ratio = 0.66; 95% confidence interval = 0.46, 0.95). Models predicted a mean postprocedural LOS difference of 0.8 days (2.8 days pre-CQI vs 2.0 days post-CQI; P <.001) and an average post-CQI cost savings of $5430 (P <.001). CONCLUSION: Physician-led, multidisciplinary practice management efforts were successful at significantly reducing PCI-related costs in an era of rapid technological advances while maintaining and perhaps improving quality of care.

Provider satisfaction in clinical encounters with ethnic immigrant patients.

OBJECTIVE: To determine whether physicians' satisfaction in clinical encounters with ethnic immigrant patients differs from satisfaction in clinical encounters with white patients in the local community. PATIENTS AND METHODS: Postvisit assessments from primary care physicians were collected for matched pairs of ethnic and control patients at the Mayo Clinic in Rochester, Minn, during a 10-week study (April 2-June 9, 2001). Ethnic patients were defined as first-generation Somalian, Cambodian, and Hispanic immigrants. Control patients were American-born white patients who were seen by the same physician and matched to the ethnic patients in age, sex, and type of visit. T tests and Hotelling T2 tests were used to analyze differences in physician responses between groups; regression analysis was used to identify the relationship between physicians' satisfaction and ethnicity in the presence of covariates. RESULTS: Physicians were considerably less satisfied with ethnic patient visits compared with control patient visits. Larger differences in satisfaction were reported in the areas of patient efforts with disease prevention and management of chronic diseases. Smaller differences in satisfaction were reported for issues related to communication and cultural beliefs and practices. These differences persisted after controlling for patient demographics, physician, and visit characteristics. CONCLUSIONS: Patients' ethnicity affects physician satisfaction with clinical encounters, particularly in the delivery of preventive care and chronic disease management.

The cost-effectiveness of acetaminophen, NSAIDs, and selective COX-2 inhibitors in the treatment of symptomatic knee osteoarthritis.

OBJECTIVE: The objective of this study was to conduct an economic evaluation of rofecoxib and celecoxib compared with high-dose acetaminophen or ibuprofen with and without misoprostol for patients with symptomatic knee osteoarthritis (OA). METHODS: A decision analysis model was designed over 6 months using two measures of effectiveness: 1) number of upper gastrointestinal (GI) adverse events averted; and 2) number of patients who achieved perceptible pain relief. Separate analyses were conducted for all patients and for those who did not respond to acetaminophen. Outcome probabilities were obtained from a comprehensive review of randomized controlled trials and observational studies. Costs were derived from actual resource utilization of OA patients. RESULTS: In terms of averting GI events, acetaminophen dominates the other options for an average risk patient population. For patients who did not respond to acetaminophen, rofecoxib had the lowest incremental cost-effectiveness ratio (ICER) per GI event avoided (32,000 US dollars) relative to ibuprofen. In terms of pain control, ibuprofen had an ICER of 610.77 US dollars per additional patient achieving minimal perceptible clinical improvement (MPCI) relative to acetaminophen, while rofecoxib had an ICER of 12,000 US dollars relative to ibuprofen. For patients who did not respond to acetaminophen and who are at high risk of developing an adverse GI event, rofecoxib dominates ibuprofen as the preferred alternative for both measures of effectiveness. One-way, two-way, and probabilistic sensitivity analyses established that these results were generally robust. CONCLUSIONS: Our results suggest that for average-risk knee OA patients, acetaminophen dominates the other therapies in terms of cost per GI event averted. In terms of pain relief, cost-effectiveness acceptability curves indicate that if one values pain relief below 275 US dollars per patient achieving MPCI, acetaminophen is the therapy most likely to be optimal; between 275 US dollars and 14,150 US dollars, ibuprofen is most likely to be optimal; and above 14,150 US dollars, rofecoxib is most likely to be optimal.