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Morgan RA. Cost: An Important Question That Must Be Asked. HEC Forum 2024; 36:61-70. [PMID: 35445874 DOI: 10.1007/s10730-022-09478-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
Cost conversations are essential to informed consent because patients have a right to information that they think is relevant, and patients overwhelmingly report that cost information is relevant to their medical decisions. Providers have an ethical responsibility to provide necessary information for informed consent, and therefore must discuss costs. The Shared Decision Making model is ideal for enabling this exchange of information, and decision aids are also helpful. Although barriers exist, many useful tools can help providers fulfill this obligation, and encouraging progress is being made to improve cost transparency from insurers and facilities.
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Affiliation(s)
- R Andrew Morgan
- Neiswanger Institute for Bioethics, Loyola University Chicago, Chicago, IL, USA.
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2
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Blum L, Jarach CM, Ellen ME. Perceptions of shared decision making in gastroenterology and inflammatory bowel disease: A qualitative analysis. PATIENT EDUCATION AND COUNSELING 2023; 115:107877. [PMID: 37437510 DOI: 10.1016/j.pec.2023.107877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Shared decision-making (SDM) is the partnership and discussion between clinicians and patients to make an appropriate decision based on scientific evidence and patient preferences. Many benefits are associated with SDM; however, little is known about its awareness or use by inflammatory bowel disease (IBD) clinicians in gastroenterology departments across Israel. This study aims to identify barriers and facilitators in implementing SDM as standard practice to achieve optimal disease management and personalized care for patients with IBD. METHODS Sixteen semi-structured interviews were conducted with IBD clinicians across Israel to identify the barriers and facilitators for SDM use. An interview guide was developed, based on the systematic approach of the Theoretical Domain Framework (TDF). Interview transcripts were coded into theoretical domains to identify factors that may impact SDM. RESULTS Sixteen gastroenterologists from nine different hospitals were interviewed. Common TDF domains that presented as barriers were: knowledge, skills, social/professional role and identity, environmental context and resources, and reinforcement. Most participants had never heard the precise term "shared decision making" and lacked formal training on SDM. CONCLUSION This study identified key barriers and facilitators to SDM in IBD clinics across Israel. Main barriers of SDM include limited or nonexistent training; clinicians were unaware of SDM guidelines or techniques. The main facilitators of SDM were clinicians' social and professional role and identity and their beliefs about the influence of IBD and/or CD. PRACTICE IMPLICATIONS These influencing factors and TDF domains identified provide a basis for developing future interventions to improve the implementation of SDM within IBD management.
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Affiliation(s)
- Livnat Blum
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel.
| | - Carlotta Micaela Jarach
- Laboratory of Lifestyle Research, Department of Medical Epidemiology, Mario Negri Institute of Pharmacological Research, IRCCS, Italy.
| | - Moriah E Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel; Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Canada; Israel Implementation Science and Policy Engagement Centre, Ben-Gurion University of the Negev, Israel.
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3
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Chen ZR, Zhang L, Chen YW, Xu MY, Jia H, Li MY, Lou YH, Lan L. Correlation analysis between physicians' evaluations of doctor-patient relationship and their preferences for shared decision-making in China. Front Psychiatry 2022; 13:946383. [PMID: 36276337 PMCID: PMC9579421 DOI: 10.3389/fpsyt.2022.946383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022] Open
Abstract
Shared decision-making (SDM) is a scientific and reasonable decision-making model. However, whether physicians choose SDM is usually influenced by many factors. It is not clear whether the strained doctor-patient relationship will affect physicians' willingness to choose SDM. Through a survey by questionnaire, 304 physicians' evaluations of doctor-patient relationship (DPR) were quantified by the difficult DPR questionnaire-8. Their preferences for SDM and the reasons were also evaluated. The correlation between physicians' evaluations of DPR and their preferences for SDM were analyzed. 84.5% physicians perceived DPR as poor or strained, 53.3% physicians preferred SDM, mainly because of the influences of medical ethics and social desirability bias. Their preferences for SDM were not significantly correlated with their evaluations of DPR (P > 0.05). Physicians with different evaluations of DPR (good, poor, and strained) all had similar preferences for SDM (42.6, 56.4, and 42.9%), with no significant difference (P > 0.05). There was no correlation between physicians' evaluations of DPR and their preferences for SDM. Physicians' evaluations of poor DPR did not affect their preferences for SDM. This may be influenced by the medical ethics and social desirability bias.
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Affiliation(s)
- Zhuo-Ran Chen
- Henan No.3 Provincial People's Hospital, Zhengzhou, China
| | - Li Zhang
- The Third People's Hospital of Zhengzhou, Zhengzhou, China
| | - Ya-Wei Chen
- GeneCast Biotechnology Co., Ltd., Beijing, China
| | | | - Hang Jia
- Nanyang City Center Hospital, Nanyang, China
| | | | - Yu-Han Lou
- Henan Provincial People's Hospital, Zhengzhou, China.,People's Hospital of Zhengzhou University, Zhengzhou, China.,People's Hospital of Henan University, Zhengzhou, China
| | - Ling Lan
- Henan Provincial People's Hospital, Zhengzhou, China.,People's Hospital of Zhengzhou University, Zhengzhou, China.,People's Hospital of Henan University, Zhengzhou, China
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Geiger F, Hacke C, Potthoff J, Scheibler F, Rueffer JU, Kuch C, Wehkamp K. The effect of a scalable online training module for shared decision making based on flawed video examples - a randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2021; 104:1568-1574. [PMID: 33334633 DOI: 10.1016/j.pec.2020.11.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Shared Decision Making (SDM) is considered the gold standard of medical decision making as it provides a method to systematically integrate the patient's preferences, evidence-based medicine and the experience of health care professionals. Therefore, evidence-based training methods for a broad implementation into healthcare are needed. A new online training was designed, based on the concept of flawed/flawless video examples and additional educational concepts. METHODS In a single-blind randomized-controlled trial, medical students were randomly assigned to intervention group receiving the online training (n = 82) or waiting control group (n = 105). SDM-related knowledge and the ability to judge distinct levels of SDM were compared between both groups. Additionally, feedback regarding the intervention was collected. RESULTS SDM-related knowledge and judging ability increased significantly in the intervention group compared to controls (SDM knowledge: mean difference: 12 %; 95 % CI: 7.3-18.5; p < 0.001; SDM judging ability (inter-rater concordance displayed by weighted t): mean difference: 0.07; 95 %CI: 0.03-0.11; p = 0.001). Feedback was positive. CONCLUSION The online training with its distinctive methodology prove effective. As it shares the theoretical and didactical background with an already existing face-to-face training, both approaches may also be used complementarily. PRACTICE IMPLICATIONS SDM can be trained effectively and efficiently with this easily scalable online training.
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Affiliation(s)
- Friedemann Geiger
- Department of Pediatrics, The SHARE TO CARE project, University Hospital Schleswig-Holstein, Kiel, Germany; Institute of Medical Psychology and Medical Sociology, University Medical Center Schleswig-Holstein, Kiel, Germany; Department of Psychology, MSH Medical School Hamburg, Hamburg, Germany.
| | - Claudia Hacke
- Department of Pediatrics, The SHARE TO CARE project, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Judith Potthoff
- Department of Pediatrics, The SHARE TO CARE project, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Fueloep Scheibler
- Department of Pediatrics, The SHARE TO CARE project, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Christine Kuch
- Department of Pediatrics, The SHARE TO CARE project, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Kai Wehkamp
- Department of Pediatrics, The SHARE TO CARE project, University Hospital Schleswig-Holstein, Kiel, Germany; Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany; Department of Medical Management, MSH Medical School Hamburg, Hamburg, Germany
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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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Stammen LA, Driessen EW, Notermans CC, Scheele F, Stassen LP, Stalmeijer RE. How Do Attending Physicians Prepare Residents to Deliver High-Value, Cost-Conscious Care? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:764-770. [PMID: 31688032 PMCID: PMC7185052 DOI: 10.1097/acm.0000000000003051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE An estimated 20% of health care expenditures are wasteful. Educational interventions aimed at reducing waste by delivering high-value, cost-conscious care (HV3C) often focus on the role of the physician. This study sought to understand how attending physicians, who have a central role in the workplace, prepare residents to provide HV3C. METHOD Researchers from Maastricht University in Maastricht, the Netherlands, conducted semistructured interviews between September 2016 and August 2017 with 12 attending physicians who supervise residents in the workplace. Participants were purposefully sampled from 5 institutions throughout the Netherlands to include surgical and nonsurgical attending physicians and hospital- and nonhospital-based physicians. Data collection and analysis were iterative, using principles of grounded theory. RESULTS The attending physician's approach to providing HV3C was an important factor in preparing residents in the workplace. Three differences became apparent: priority of HV3C training, feedback on HV3C, and obstacles to HV3C delivery. Results indicate that attending physicians use 3 teaching methods to teach HV3C delivery: Socratic questioning, role modeling, and setting limits. Training was often implicit and ad hoc. CONCLUSIONS How attending physicians deal with HV3C themselves influences how they prepare residents in the workplace. To optimize resident training, it may be important to create a supportive environment for HV3C delivery and training. Delivery could be supported by making HV3C a shared goal for attending physicians and residents, thereby providing insight into clinical practice behavior and minimizing the influence of obstacles. Training could be optimized by supporting a variety of teaching methods suitable for daily teaching to stimulate continuous learning in residents.
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Affiliation(s)
- Lorette A. Stammen
- L.A. Stammen is a family medicine resident and PhD candidate in the field of medical education, School of Health Professions Education, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands; ORCID: https://orcid.org/0000-0003-1528-546X
| | - Erik W. Driessen
- E.W. Driessen is professor of medical education, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands; ORCID: https://orcid.org/0000-0001-8115-261X
| | - Celine C.V.I. Notermans
- C.C.V.I. Notermans is a master student in the medicine program, Faculty of Health, Medicine and Life Sciences, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands
| | - Fedde Scheele
- F. Scheele is professor of health systems innovation and medical education, Athena Institute, VU School of Medical Sciences, Amsterdam UMC, and gynecologist at the OLVG Hospital Amsterdam, Amsterdam, the Netherlands; ORCID: https://orcid.org/0000-0001-9593-257X
| | - Laurents P.S. Stassen
- L.P.S. Stassen is professor of medical education and gastrointestinal surgeon, Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; ORCID: https://orcid.org/0000-0002-3383-9035
| | - Renée E. Stalmeijer
- R.E. Stalmeijer is assistant professor and qualitative researcher, School of Health Professions Education, Department of Educational Research and Development, Maastricht University, Maastricht, Limburg, the Netherlands; ORCID: https://orcid.org/0000-0001-8690-5326
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Covvey JR, Kamal KM, Gorse EE, Mehta Z, Dhumal T, Heidari E, Rao D, Zacker C. Barriers and facilitators to shared decision-making in oncology: a systematic review of the literature. Support Care Cancer 2019; 27:1613-1637. [DOI: 10.1007/s00520-019-04675-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/28/2019] [Indexed: 01/20/2023]
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8
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Leep Hunderfund AN, Dyrbye LN, Starr SR, Mandrekar J, Naessens JM, Tilburt JC, George P, Baxley EG, Gonzalo JD, Moriates C, Goold SD, Carney PA, Miller BM, Grethlein SJ, Fancher TL, Reed DA. Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences With Cost-Conscious Care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:694-702. [PMID: 27191841 DOI: 10.1097/acm.0000000000001223] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care. METHOD Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index. RESULTS Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001). CONCLUSIONS Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.
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Affiliation(s)
- Andrea N Leep Hunderfund
- A.N. Leep Hunderfund is assistant professor of neurology, Mayo Clinic, Rochester, Minnesota. L.N. Dyrbye is professor of medical education and medicine, Mayo Clinic, Rochester, Minnesota. S.R. Starr is assistant professor of pediatric and adolescent medicine and director, Science of Health Care Delivery Education, Mayo Medical School, Mayo Clinic, Rochester, Minnesota. J. Mandrekar is professor of biostatistics and neurology, Mayo Clinic, Rochester, Minnesota. J.M. Naessens is professor of health services research, Mayo Clinic, Rochester, Minnesota. J.C. Tilburt is professor of medicine and associate professor of biomedical ethics, Mayo Clinic, Rochester, Minnesota. P. George is associate professor of family medicine and associate professor of medical science, Warren Alpert Medical School, Brown University, Providence, Rhode Island. E.G. Baxley is professor of family medicine and senior associate dean of academic affairs, Brody School of Medicine, East Carolina University, Greenville, North Carolina. J.D. Gonzalo is assistant professor of medicine and public health sciences and associate dean for health systems education, Pennsylvania State University College of Medicine, Hershey, Pennsylvania. C. Moriates is assistant clinical professor, Division of Hospital Medicine, and director, Caring Wisely Program, University of California San Francisco, San Francisco, California. S.D. Goold is professor of internal medicine and health management, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan. P.A. Carney is professor of family medicine and of public health and preventive medicine, Oregon Health & Science University, Portland, Oregon. B.M. Miller is professor of medical education and administration, professor of clinical surgery, associate vice chancellor for health affairs, and senior associate dean for health sciences education, Vanderbilt University, Nashville, Tennessee. S.J. Grethlein is professor of clinical medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana. T.L. Fancher is associate professor of medicine, Division of General Medicine, University of California Davis, Sacramento, California. D.A. Reed is associate professor of medical education and medicine and senior associate dean of academic affairs, Mayo Medical School, Mayo Clinic, Rochester, Minnesota
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Henrikson NB, Chang E, Ulrich K, King D, Anderson ML. Communication with Physicians about Health Care Costs: Survey of an Insured Population. Perm J 2017; 21:16-070. [PMID: 28406786 PMCID: PMC5391781 DOI: 10.7812/tpp/16-070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
CONTEXT Health care costs have increasingly shifted to patients, and financial distress caused by medical care has increased. Patients may wish to discuss costs with their clinicians. OBJECTIVE Describe patient preferences for communication about cost in the clinical setting. DESIGN Cross-sectional, self-administered survey of a stratified random sample of the population insured in an integrated health care system in Washington State. Our sampling frame was the entire membership aged 21 years or older. Sampling was stratified by sex and group practice enrollment. MAIN OUTCOME MEASURES Preference for discussing health care costs with one's physician. We conducted regression analyses to determine predictors of communication preference; potential predictors included demographic characteristics, financial burden, delay in seeking care because of cost, and socioeconomic variables. Survey responses were weighted to adjust for nonresponse and sampling. RESULTS Of 7200 invitations sent, 2200 survey responses were returned. Ninety-two percent wished to know their out-of-pocket costs before beginning treatment. Most respondents preferred their physician talk with them about out-of-pocket costs (81.4%) and expressed comfort with discussing costs with their physician (75.6%). Overall, 43.7% reported any delay in seeking care in the previous 12 months. One in 5 respondents (21.6%) reported family medical debt. Delay in seeking care was positively and independently associated with preferring to discuss costs with one's physician; current medical financial burden was not. CONCLUSION Patient preferences for communication about costs with physicians are high, and medical debt and delay in care-seeking are prevalent. Delay in care-seeking independently predicts cost communication preferences.
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Affiliation(s)
- Nora B Henrikson
- Research Associate at Kaiser Permanente Washington Health Research Institute, formerly Group Health Research Institute, in Seattle, WA.
| | - Eva Chang
- Research Public Health Analyst from the Division of Health Services and Social Policy at RTI International in Waltham, MA.
| | - Kevin Ulrich
- Director of the Survey Lab Research Center from the Division of the Social Sciences at the University of Chicago in IL.
| | - Deborah King
- Research Interventionist at Kaiser Permanente Washington Health Research Institute, formerly Group Health Research Institute, in Seattle, WA.
| | - Melissa L Anderson
- Senior Biostatistician at Kaiser Permanente Washington Health Research Institute, formerly Group Health Research Institute, in Seattle, WA.
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