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Miller ME, Donohue P, Seltzer R, Kwak C, Boss RD. Costs of Neonatal Medical Complexity: Impact on New Parent Stress and Decision-Making. Am J Perinatol 2024; 41:e833-e842. [PMID: 36130670 DOI: 10.1055/a-1948-2580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Parents of children with medical complexity experience substantial financial burdens. It is unclear how neonatal intensive care unit (NICU) clinicians prepare new parents of medically complex infants for this reality. This study explored new parent awareness of health care costs, desire to discuss costs with clinicians, and impact of costs on parents' medical decision-making. STUDY DESIGN The study design comprised semistructured interviews and surveys of parents of infants with medical complexity currently or previously in a NICU. Conventional content analysis was performed on interview transcripts, and descriptive analyses were applied to surveys. RESULTS Thematic saturation was reached with 27 families (15 NICU families and 12 post-NICU families) of diverse race/ethnicity/education/household income. Most were worried about their infants' current/future medical expenses and approximately half wanted to discuss finances with clinicians, only one parent had. While finances were not part of most parent's NICU decision-making, some later regretted this and wished cost had been incorporated into treatment choices. The family desire to discuss costs did not vary by family financial status. Parents described their infant's health care costs as: "We are drowning"; and "We'll never pay it off." CONCLUSION Most parents were worried about current and future medical expenses related to their infant's evolving medical complexity. Many wanted to discuss costs with clinicians; almost none had. NICU clinicians should prepare families for the future financial realities of pediatric medical complexity. KEY POINTS · Many families want to discuss costs with NICU clinicians.. · Some families want costs to be a part of medical decisions.. · Few families currently discuss costs with NICU providers..
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Affiliation(s)
- Mattea E Miller
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Pamela Donohue
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Population and Family Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rebecca Seltzer
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Population and Family Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Berman Institute of Bioethics, Baltimore, Maryland
| | - Cecilia Kwak
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Baltimore, Maryland
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Garcia-Bautista A, Kamath C, Ayala N, Behnken E, Giblon RE, Gravholt D, Hernández-Leal MJ, Hidalgo J, Leon Garcia M, Golembiewski EH, Maraboto A, Sivly A, Brito JP. Financial Toxicity in the Clinical Encounter: A Paired Survey of Patient and Clinician Perceptions. Mayo Clin Proc Innov Qual Outcomes 2023; 7:248-255. [PMID: 37359420 PMCID: PMC10285501 DOI: 10.1016/j.mayocpiqo.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Objective To compare the agreement between patient and clinician perceptions of care-related financial issues. Patients and Methods We surveyed patient-clinician dyads immediately after an outpatient medical encounter between September 2019 and May 2021. They were asked to separately rate (1-10) patient's level of difficulty in paying medical bills and the importance of discussing cost issues with that patient during clinical encounters. We calculated agreement between patient-clinician ratings using the intraclass correlation coefficient and used random effects regression models to identify patient predictors of paired score differences in difficulty and importance of ratings. Results 58 pairs of patients (n=58) and clinicians (n=40) completed the survey. Patient-clinician agreement was poor for both measures, but higher for difficulty in paying medical bills (intraclass correlation coefficient=0.375; 95% CI, 0.13-0.57) than for the importance of discussing cost (-0.051; 95% CI, -0.31 to 0.21). Agreement on difficulty in paying medical bills was not lower in encounters with conversations about the cost of care. In adjusted models, poor patient-clinician agreement on difficulty in paying medical bills was associated with lower patient socioeconomic status and education level, whereas poor agreement on patient-perceived importance of discussing cost was significant for patients who were White, married, reported 1 or more long-term conditions, and had higher education and income levels. Conclusion Even in encounters where cost conversations occurred, there was poor patient-clinician agreement on ratings of the patient's difficulty in paying medical bills and perceived importance of discussing cost issues. Clinicians need more training and support in detecting the level of financial burden and tailoring cost conversations to the needs of individual patients.
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Affiliation(s)
- Andrea Garcia-Bautista
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Celia Kamath
- Robert D and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Nicolas Ayala
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Emma Behnken
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Rachel E Giblon
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Derek Gravholt
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - María José Hernández-Leal
- Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Pamplona, Spain
- Medical Sciences, Universidad de La Frontera, Temuco, Chile
- Millenium Nucleus of Sociomedicine (Sociomed), Santiago, Chile
| | - Jessica Hidalgo
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Montserrat Leon Garcia
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
- Iberoamerican Cocharane Center, Biomedical Research Institute Sant Pau, Barcelona, Spain
| | | | - Andrea Maraboto
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Angela Sivly
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Juan P Brito
- Department of Medicine, Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
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Gordon LG, Nabukalu D, Chan RJ, Goldsbury DE, Hobbs K, Hunt L, Karikios DJ, Mackay G, Muir L, Leigh L, Thamm C, Lindsay D, Whittaker K, Varlow M, McLoone J, Financial Toxicity Working Group OBOTC. Opinions and strategies of Australian health professionals on tackling cancer-related financial toxicity: A nationwide survey. Asia Pac J Clin Oncol 2023; 19:126-135. [PMID: 35589922 DOI: 10.1111/ajco.13786] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 01/20/2023]
Abstract
AIM To understand the opinions and current practices of health professionals on the topic of addressing cancer-related financial toxicity among patients. METHODS A cross-sectional online survey was distributed through Australian clinical oncology professional organizations/networks. The multidisciplinary Clinical Oncology Society of Australia Financial Toxicity Working Group developed 25 questions relating to the frequency and comfort levels of patient-clinician discussions, opinions about their role, strategies used, and barriers to providing solutions for patients. Descriptive statistics were used and subgroup analyses were undertaken by occupational groups. RESULTS Two hundred and seventy-seven health professionals completed the survey. The majority were female (n = 213, 77%), worked in public facilities (200, 72%), and treated patients with varied cancer types across all of Australia. Most participants agreed that it was appropriate in their clinical role to discuss financial concerns and 231 (88%) believed that these discussions were an important part of high-quality care. However, 73 (28%) stated that they did not have the appropriate information on support services or resources to facilitate such conversations, differing by occupation group; 7 (11%) social workers, 34 (44%) medical specialists, 18 (25%) nurses, and 14 (27%) of other occupations. Hindrances to discussing financial concerns were insufficient resources or support systems to refer to, followed by lack of time in a typical consultation. CONCLUSION Health professionals in cancer care commonly address the financial concerns of their patients but attitudes differed across occupations about their role, and frustrations were raised about available solutions. Resources supporting financial-related discussions for all health professionals are urgently needed to advance action in this field.
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Affiliation(s)
- Louisa G Gordon
- QIMR Berghofer Medical Research Institute, Population Health Department, Brisbane, Herston, Australia.,Queensland University of Technology (QUT), School of Nursing and Cancer and Palliative Care Outcomes Centre, Brisbane, Kelvin Grove, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Herston, Australia
| | - Doreen Nabukalu
- QIMR Berghofer Medical Research Institute, Population Health Department, Brisbane, Herston, Australia
| | - Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - David E Goldsbury
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Kim Hobbs
- Oncology Social Work Australia & New Zealand/Westmead Hospital NSW, Westmead, New South Wales, Australia
| | - Lee Hunt
- Cancer Voices NSW, Sydney NSW, Australia
| | - Deme J Karikios
- Department of Medical Oncology, Nepean Hospital, Kingswood, New South Wales, Australia.,Nepean Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Gillian Mackay
- Clinical Oncology Society of Australia, Sydney, New South Wales, Australia
| | - Laura Muir
- Cancer Council NSW, Sydney, New South Wales, Australia
| | | | - Carla Thamm
- Queensland University of Technology (QUT), School of Nursing and Cancer and Palliative Care Outcomes Centre, Brisbane, Kelvin Grove, Australia
| | - Daniel Lindsay
- Faculty of Medicine, University of Queensland, Brisbane, Herston, Australia
| | | | | | - Jordana McLoone
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital NSW, Sydney, New South Wales, Australia.,Discipline of Paediatrics & Child Health, UNSW Medicine & Health, Randwick Clinical Campus, University of NSW, Sydney, New South Wales, Australia
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Espinoza Suarez NR, LaVecchia CM, Morrow AS, Fischer KM, Kamath C, Boehmer KR, Brito JP. ABLE to support patient financial capacity: A qualitative analysis of cost conversations in clinical encounters. PATIENT EDUCATION AND COUNSELING 2022; 105:3249-3258. [PMID: 35918230 DOI: 10.1016/j.pec.2022.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To explore how costs of care are discussed in real clinical encounters and what humanistic elements support them. METHODS A qualitative thematic analysis of 41 purposively selected transcripts of video-recorded clinical encounters from trials run between 2007 and 2015. Videos were obtained from a corpus of 220 randomly selected videos from 8 practice-based randomized trials and 1 pre-post prospective study comparing care with and without shared decision making (SDM) tools. RESULTS Our qualitative analysis identified two major themes: the first, Space Needed for Cost Conversations, describes patients' needs regarding their financial capacity. The second, Caring Responses, describes humanistic elements that patients and clinicians can bring to clinical encounters to include good quality cost conversations. CONCLUSION Our findings suggest that strengthening patient-clinician human connections, focusing on imbalances between patient resources and burdens, and providing space to allow potentially unexpected cost discussions to emerge may best support high quality cost conversations and tailored care plans. PRACTICE IMPLICATIONS We recommend clinicians consider 4 aspects of communication, represented by the mnemonic ABLE: Ask questions, Be kind and acknowledge emotions, Listen for indirect signals and (discuss with) Every patient. Future research should evaluate the practicality of these recommendations, along with system-level improvements to support implementation of our recommendations.
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Affiliation(s)
- Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Centre for Sustainable Health Research, Laval University, Quebec, QC, Canada
| | | | - Allison S Morrow
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Milken Institute School of Public Health, The George Washington University, Washington DC, USA
| | - Karen M Fischer
- Division of Biomedical Statistics and Informatics, Mayo Clinic, MN, USA
| | - Celia Kamath
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, MN, USA.
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5
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Silva MD, Charlo PB, Zulin A, Santos FGTD, Jaques AE, Haddad MDCFL, Radovanovic CAT. Construction and validation of clinical scenarios for training informal caregivers of dependent persons. Rev Bras Enferm 2022; 75:e20220140. [PMID: 36259877 DOI: 10.1590/0034-7167-2022-0140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/04/2022] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To construct and validate three clinical scenarios for training dependent persons' informal caregivers. METHODS Methodological study, conducted between January and August 2021, in a municipality in the northwest of the state of Paraná. It was developed in two stages: construction of scenarios; and content validation by experts (n = 12). To estimate the degree of agreement between the experts, the content validity index was used, and 80% was considered an acceptable rate of agreement. RESULTS The simulation scenarios proved appropriate, obtaining an average value of 91.6%. However, some adjustments were made in their organization pertaining clarity in the wording of guidelines, as suggested by the expert validators. CONCLUSIONS The construction and validation of the clinical scenarios proved to be adequate and relevant for use in the training of informal caregivers of dependent persons.
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Affiliation(s)
| | | | - Aline Zulin
- Universidade Estadual de Maringá. Maringá, Paraná, Brazil
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Espinoza Suarez NR, Urtecho M, LaVecchia CM, Fischer KM, Kamath CC, Brito JP. Impact of Cost Conversations During Clinical Encounters Aided by Shared Decision-Making Tools on Medication Adherence. Mayo Clin Proc Innov Qual Outcomes 2022; 6:320-326. [PMID: 35782878 PMCID: PMC9240368 DOI: 10.1016/j.mayocpiqo.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nataly R. Espinoza Suarez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
- VITAM—Centre for Sustainable Health Research, Laval University, Quebec City, QC, Canada
| | | | | | - Karen M. Fischer
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Celia C. Kamath
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery and Research, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
- Correspondence: Address to Juan P. Brito, MBBS, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55902.
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7
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Kiessling KA, Iott BE, Pater JA, Toscos TR, Wagner SR, Gottlieb LM, Veinot TC. Health informatics interventions to minimize out-of-pocket medication costs for patients: what providers want. JAMIA Open 2022; 5:ooac007. [PMID: 35274083 PMCID: PMC8903137 DOI: 10.1093/jamiaopen/ooac007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/13/2021] [Accepted: 01/31/2022] [Indexed: 11/14/2022] Open
Abstract
Objective To explore diverse provider perspectives on: strategies for addressing patient medication cost barriers; patient medication cost information gaps; current medication cost-related informatics tools; and design features for future tool development. Materials and Methods We conducted 38 semistructured interviews with providers (physicians, nurses, pharmacists, social workers, and administrators) in a Midwestern health system in the United States. We used 3 rounds of qualitative coding to identify themes. Results Providers lacked access to information about: patients’ ability to pay for medications; true costs of full medication regimens; and cost impacts of patient insurance changes. Some providers said that while existing cost-related tools were helpful, they contained unclear insurance information and several questioned the information’s quality. Cost-related information was not available to everyone who needed it and was not always available when needed. Fragmentation of information across sources made cost-alleviation information difficult to access. Providers desired future tools to compare medication costs more directly; provide quick references on costs to facilitate clinical conversations; streamline medication resource referrals; and provide centrally accessible visual summaries of patient affordability challenges. Discussion These findings can inform the next generation of informatics tools for minimizing patients’ out-of-pocket costs. Future tools should support the work of a wider range of providers and situations and use cases than current tools do. Such tools would have the potential to improve prescribing decisions and better link patients to resources. Conclusion Results identified opportunities to fill multidisciplinary providers’ information gaps and ways in which new tools could better support medication affordability for patients. Almost a quarter of Americans taking prescription medications have difficulty affording them. We asked 38 healthcare providers what they do to help patients get affordable medications. They try to reduce the number of medications that patients take, choose more affordable medication options, and connect them to free medications or financial help. But it is hard for providers to do these things because they don’t always know which patients have financial challenges, and they may not know how much medications cost patients. Healthcare providers use digital tools like ordering systems to pick medications for patients, but they do not always have clear price information and they do not help outside of healthcare visits with prescribers. It is also hard for healthcare providers to get information about what patients have difficulty affording medications, and about resources to help them. Healthcare providers want new and improved digital tools to help them choose medications, and to be able to compare exact medication price differences. They also want a visual sign for patients with financial challenges, and centralized information about cost reduction resources. Finally, they desire tools to help them talk to patients about mediation prices, and medication price reports for patients themselves.
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Affiliation(s)
| | - Bradley E Iott
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- School of Information, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica A Pater
- Parkview Mirro Center for Research & Innovation, Parkview Health, Fort Wayne, Indiana, USA
| | - Tammy R Toscos
- Parkview Mirro Center for Research & Innovation, Parkview Health, Fort Wayne, Indiana, USA
| | - Shauna R Wagner
- Parkview Mirro Center for Research & Innovation, Parkview Health, Fort Wayne, Indiana, USA
| | - Laura M Gottlieb
- Social Interventions Research and Evaluation Network, University of California San Francisco, San Francisco, California, USA
| | - Tiffany C Veinot
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- School of Information, University of Michigan, Ann Arbor, Michigan, USA
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Richards OK, Iott BE, Toscos TR, Pater JA, Wagner SR, Veinot TC. "It's a mess sometimes": patient perspectives on provider responses to healthcare costs, and how informatics interventions can help support cost-sensitive care decisions. J Am Med Inform Assoc 2022; 29:1029-1039. [PMID: 35182148 PMCID: PMC9093030 DOI: 10.1093/jamia/ocac010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 12/13/2021] [Accepted: 01/28/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We investigated patient experiences with medication- and test-related cost conversations with healthcare providers to identify their preferences for future informatics tools to facilitate cost-sensitive care decisions. MATERIALS AND METHODS We conducted 18 semistructured interviews with diverse patients (ages 24-81) in a Midwestern health system in the United States. We identified themes through 2 rounds of qualitative coding. RESULTS Patients believed their providers could help reduce medication-related costs but did not see how providers could influence test-related costs. Patients viewed cost conversations about medications as beneficial when providers could adjust medical recommendations or provide resources. However, cost conversations did not always occur when patients felt they were needed. Consequently, patients faced a "cascade of work" to address affordability challenges. To prevent this, collaborative informatics tools could facilitate cost conversations and shared decision-making by providing information about a patient's financial constraints, enabling comparisons of medication/testing options, and addressing transportation logistics to facilitate patient follow-through. DISCUSSION Like providers, patients want informatics tools that address patient out-of-pocket costs. They want to discuss healthcare costs to reduce the frequency of unaffordable costs and obtain proactive assistance. Informatics interventions could minimize the cascade of patient work through shared decision-making and preventative actions. Such tools might integrate information about efficacy, costs, and side effects to support decisions, present patient decision aids, facilitate coordination among healthcare units, and eventually improve patient outcomes. CONCLUSION To prevent a burdensome cascade of work for patients, informatics tools could be designed to support cost conversations and decisions between patients and providers.
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Affiliation(s)
- Olivia K Richards
- University of Michigan, School of Information, Ann Arbor, Michigan, USA
| | - Bradley E Iott
- University of Michigan, School of Information, Ann Arbor, Michigan, USA
| | - Tammy R Toscos
- Parkview Mirro Center for Research & Innovation, Fort Wayne, Indiana, USA
| | - Jessica A Pater
- Parkview Mirro Center for Research & Innovation, Fort Wayne, Indiana, USA
| | - Shauna R Wagner
- Parkview Mirro Center for Research & Innovation, Fort Wayne, Indiana, USA
| | - Tiffany C Veinot
- Corresponding Author: Tiffany C. Veinot, MLS, PhD, University of Michigan, 4314 North Quad, 105 S. State Street, Ann Arbor, MI 48109-1285, USA;
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Silva MD, Charlo PB, Zulin A, Santos FGTD, Jaques AE, Haddad MDCFL, Radovanovic CAT. Construção e validação de cenários clínicos para capacitação de cuidadores informais de pessoas dependentes. Rev Bras Enferm 2022. [DOI: 10.1590/0034-7167-2022-0140pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
RESUMO Objetivo: Construir e validar três cenários clínicos para capacitação de cuidadores informais de pessoas dependentes. Métodos: Estudo metodológico, realizado entre janeiro e agosto de 2021, em um município no noroeste do estado do Paraná. Foi desenvolvido em duas etapas: construção dos cenários; e validação do conteúdo por experts (n = 12). Para estimar o grau de concordância entre os juízes, utilizou-se o índice de validade de conteúdo, e considerou-se o valor de 80% como uma taxa aceitável de concordância. Resultados: Os cenários de simulação mostraram-se apropriados, obtendo valor médio de 91,6%. No entanto, foram feitos alguns ajustes em sua organização no que tange à clareza na redação das orientações, conforme sugestão dos juízes. Conclusões: A construção e validação dos cenários clínicos mostraram-se adequadas e relevantes, de modo que eles podem ser utilizados na capacitação de cuidadores informais de pessoas dependentes.
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Abstract
IMPORTANCE One-third of US residents have trouble paying their medical bills. They often turn to their physicians for help navigating health costs and insurance coverage. OBJECTIVE To determine whether physicians can accurately estimate out-of-pocket expenses when they are given all of the necessary information about a drug's price and a patient's insurance plan. DESIGN, SETTING, AND PARTICIPANTS This national mail-in survey used a random sample of US physicians. The survey was sent to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). Physicians were excluded if they were in training, worked primarily for the Veterans Administration or Indian Health Service, were retired, or reported 0% outpatient clinical effort. Analyses were performed from July to December 2020. MAIN OUTCOMES AND MEASURES In a hypothetical vignette, a patient was prescribed a new drug costing $1000/month without insurance. A summary of her private insurance information was provided, including the plan's deductible, coinsurance rates, copays, and out-of-pocket maximum. Physicians were asked to estimate the drug's out-of-pocket cost at 4 time points between January and December, using the plan's 4 types of cost-sharing: (1) deductibles, (2) coinsurance, (3) copays, and (4) out-of-pocket maximums. Multivariate linear regression was used to assess differences in performance by specialty, adjusting for attitudes toward cost conversations, demographics, and clinical characteristics. RESULTS The response rate was 45% (405 of 900) and 371 respondents met inclusion criteria. Among the respondents included in this study, 59% (n = 220) identified as male, 23% (n = 84) as Asian, 3% (n = 12) as Black, 6% (n = 24) as Hispanic, and 58% (n = 216) as White; 30% (n = 112) were primary care physicians, 35% (n = 128) were gastroenterologists, and 35% (n = 131) were rheumatologists; and the mean (SD) age was 49 (10) years. Overall, 52% of physicians (n = 192) accurately estimated costs before the deductible was met, 62% (n = 228) accurately used coinsurance information, 61% (n = 224) accurately used copay information, and 57% (n = 210) accurately estimated costs once the out-of-pocket maximum was met. Only 21% (n = 78) of physicians answered all 4 questions correctly. Ability to estimate out-of-pocket costs was not associated with specialty, attitudes toward cost conversations, or clinic characteristics. CONCLUSIONS AND RELEVANCE This survey study found that many US physicians have difficulty estimating out-of-pocket costs, even when they have access to their patients' insurance plans. The mechanics involved in calculating real-time out-of-pocket costs are complex. These findings suggest that increased price transparency and simpler insurance cost-sharing mechanisms are needed to enable informed cost conversations at the point of prescribing.
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Affiliation(s)
- Caroline E. Sloan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Lorena Millo
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Peter A. Ubel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
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Gunn AH, Sorenson C, Greenup RA. Navigating the high costs of cancer care: opportunities for patient engagement. Future Oncol 2021; 17:3729-3742. [PMID: 34296620 DOI: 10.2217/fon-2021-0341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Over the past decade, the financial burden of cancer care on patients and their families has garnered increased attention. Many of the potential solutions have focused on system-level interventions such as adopting value-based payment models and negotiating drug prices; less consideration has been given to actions at the patient level to address cancer care costs. We argue that it is imperative to develop and support patient-level strategies that engage patients and consider their preferences, values and individual circumstances. Opportunities to meet these aims and improve the economic experience of patients in oncology are discussed, including: shared decision-making and communication, financial navigation and treatment planning, digital technology and alternative care pathways, and value-based insurance design.
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Affiliation(s)
- Alexander H Gunn
- School of Medicine, Duke University, Durham, NC 27710, USA.,Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27710, USA
| | - Corinna Sorenson
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27710, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC 27708, USA.,Sanford School of Public Policy, Duke University, Durham, NC 27710, USA
| | - Rachel A Greenup
- Department of Surgery, School of Medicine, Yale University, New Haven, CT 06510, USA.,Smilow Cancer Hospital, Yale University, New Haven, CT 06510, USA.,Yale Cancer Center, Yale University, New Haven, CT 06510, USA
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Kamath CC, Giblon R, Kunneman M, Lee AI, Branda ME, Hargraves IG, Sivly AL, Bellolio F, Jackson EA, Burnett B, Gorr H, Torres Roldan VD, Spencer-Bonilla G, Shah ND, Noseworthy PA, Montori VM, Brito JP. Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116009. [PMID: 34255051 PMCID: PMC8278261 DOI: 10.1001/jamanetworkopen.2021.16009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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.
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Affiliation(s)
- Celia C. Kamath
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Rachel Giblon
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Marlene Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander I. Lee
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Colorado School of Public Health, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Angela L. Sivly
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Elizabeth A. Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Lois Park, Minnesota
| | - Haeshik Gorr
- Division of General Internal Medicine, Hennepin Health, Minneapolis, Minnesota
| | - Victor D. Torres Roldan
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Peter A. Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Politi MC, Forcino RC, Parrish K, Durand MA, O'Malley AJ, Elwyn G. Cost talk: protocol for a stepped-wedge cluster randomized trial of an intervention helping patients and urologic surgeons discuss costs of care for slow-growing prostate cancer during shared decision-making. Trials 2021; 22:422. [PMID: 34187547 PMCID: PMC8240421 DOI: 10.1186/s13063-021-05369-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Costs of care are important to patients making cancer treatment decisions, but clinicians often do not feel prepared to discuss treatment costs. We aim to (1) assess the impact of a conversation-based decision aid (Option Grid) containing cost information about slow-growing prostate cancer management options, combined with urologic surgeon training, on the frequency and quality of patient-urologic surgeon cost conversations, and (2) examine the impact of the decision aid and surgeon training on decision quality. METHODS We will conduct a stepped-wedge cluster randomized trial in outpatient urology practices affiliated with a large academic medical center in the USA. We will randomize five urologic surgeons to four intervention sequences and enroll their patients with a first-time diagnosis of slow-growing prostate cancer independently at each period. Primary outcomes include frequency of cost conversations, initiator of cost conversations, and whether or not a referral is made to address costs. These outcomes will be collected by patient report (post-visit survey) and by observation (audio-recorded clinic visits) with consent. Other outcomes include the following: patient-reported decisional conflict post-visit and at 3-month follow-up, decision regret at 3-month follow-up, shared decision-making post-visit, communication post-visit, and financial toxicity post-visit and at 3-month follow-up; clinician-reported attitudes about shared decision-making before and after the study, and feasibility of sustained intervention use. We will use hierarchical regression analysis to assess patient-level outcomes, including urologic surgeon as a random effect to account for clustering of patient participants. DISCUSSION This study evaluates a two-part intervention to improve cost discussions between urologic surgeons and patients when deciding how to manage slow-growing prostate cancer. Establishing the effectiveness of the strategy under study will allow for its replication in other clinical decision contexts. TRIAL REGISTRATION ClinicalTrials.gov NCT04397016 . Registered on 21 May 2020.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8100, St. Louis, MO, 63110, USA.
| | - Rachel C Forcino
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
| | - Katelyn Parrish
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8100, St. Louis, MO, 63110, USA
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA.,Université Toulouse III Paul Sabatier, Toulouse, France
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
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Espinoza Suarez NR, LaVecchia CM, Fischer KM, Kamath CC, Brito JP. Impact of Cost Conversation on Decision-Making Outcomes. Mayo Clin Proc Innov Qual Outcomes 2021; 5:802-810. [PMID: 34401656 PMCID: PMC8358194 DOI: 10.1016/j.mayocpiqo.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Christina M LaVecchia
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,School of Arts and Sciences, Neumann University, Aston, PA
| | - Karen M Fischer
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Celia C Kamath
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN.,Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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Scholl I, Kobrin S, Elwyn G. "All about the money?" A qualitative interview study examining organizational- and system-level characteristics that promote or hinder shared decision-making in cancer care in the United States. Implement Sci 2020; 15:81. [PMID: 32957962 PMCID: PMC7507661 DOI: 10.1186/s13012-020-01042-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/07/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Despite decades of ethical, empirical, and policy support, shared decision-making (SDM) has failed to become standard practice in US cancer care. Organizational and health system characteristics appear to contribute to the difficulties in implementing SDM in routine care. However, little is known about the relevance of the different characteristics in specific healthcare settings. The aim of the study was to explore how organizational and health system characteristics affect SDM implementation in US cancer care. METHODS We conducted semi-structured interviews with diverse cancer care stakeholders in the USA. Of the 36 invited, 30 (83%) participants consented to interview. We used conventional content analysis to analyze transcript content. RESULTS The dominant theme in the data obtained was that concerns regarding a lack of revenue generation, or indeed, the likely loss of revenue, were a major barrier preventing implementation of SDM. Many other factors were prominent as well, but the view that SDM might impair organizational or individual profit margins and reduce the income of some health professionals was widespread. On the organizational level, having leadership support for SDM and multidisciplinary teams were viewed as critical to implementation. On the health system level, views diverged on whether embedding tools into electronic health records (EHRs), making SDM a criterion for accreditation and certification, and enacting legislation could promote SDM implementation. CONCLUSION Cancer care in the USA has currently limited room for SDM and is prone to paying lip service to the idea. Implementation efforts in US cancer care need to go further than interventions that target only the clinician-patient level. On a policy level, SDM could be included in alternative payment models. However, its implementation would need to be thoroughly assessed in order to prevent further misdirected incentivization through box ticking.
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Affiliation(s)
- Isabelle Scholl
- Dartmouth College, The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA.
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W26, 20246, Hamburg, Germany.
| | - Sarah Kobrin
- Healthcare Delivery Research Program, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Glyn Elwyn
- Dartmouth College, The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA
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