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Montembeau SC, Rao BR, Mitchell AR, Speight CD, Allen LA, Halpern SD, Ko YA, Matlock DD, Moore MA, Morris AA, Scherer LD, Ubel P, Dickert NW. Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF): A Trial Providing Out-of-Pocket Costs for Heart Failure Medications during Clinical Encounters. Am Heart J 2024; 269:84-93. [PMID: 38096946 PMCID: PMC11002964 DOI: 10.1016/j.ahj.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/05/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) often entails substantial out-of-pocket costs that can vary appreciably between patients. This has raised concerns regarding financial toxicity, equity, and adherence to medical therapy. In spite of these concerns, cost discussions in the HFrEF population appear to be rare, partly because out-of-pocket costs are generally unavailable during clinical encounters. In this trial, out-of-pocket cost information is given to patients and clinicians during outpatient encounters with the aim to assess the impact of providing this information on medication discussions and decisions. HYPOTHESIS Cost-informed decision-making will be facilitated by providing access to patient-specific out-of-pocket cost estimates at the time of clinical encounter. DESIGN Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF) is a multicenter trial based at Emory Healthcare and University of Colorado Health. Adapting an existing patient activation tool from the EPIC-HF trial, patients and clinicians are presented a checklist with medications approved for treatment of HFrEF with or without patient-specific out-of-pocket costs (obtained from a financial navigation firm). Clinical encounters are audio-recorded, and patients are surveyed about their experience. The trial utilizes a stepped-wedge cluster randomized design, allowing for each site to enroll control and intervention group patients while minimizing contamination of the control arm. DISCUSSION This trial will elucidate the potential impact of robust cost disclosure efforts and key information regarding patient and clinician perspectives related to cost and cost communication. It also will reveal important challenges associated with providing out-of-pocket costs for medications during clinical encounters. Acquiring medication costs for this trial requires an involved process and outsourcing of work. In addition, costs may change throughout the year, raising questions regarding what specific information is most valuable. These data will represent an important step towards understanding the role of integrating cost discussions into heart failure care. CLINICALTRIALS GOV IDENTIFIER NCT04793880.
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Affiliation(s)
- Sarah C Montembeau
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Birju R Rao
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Andrea R Mitchell
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Candace D Speight
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Larry A Allen
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center and Department of Medicine, Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yi-An Ko
- Department of Biostatistics, Emory University Rollins School of Public Health, Atlanta, GA
| | - Daniel D Matlock
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Miranda A Moore
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Alanna A Morris
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Laura D Scherer
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Peter Ubel
- Duke University Fuqua School of Business, Durham, NC
| | - Neal W Dickert
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
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Gunn AH, Warraich HJ, Mentz RJ. Costs of care and financial hardship among patients with heart failure. Am Heart J 2024; 269:94-107. [PMID: 38065330 DOI: 10.1016/j.ahj.2023.12.001] [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] [Received: 08/01/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 01/09/2024]
Abstract
With the implementation of new therapies, more patients are living with heart failure (HF) as a chronic condition. Alongside these advances, out-of-pocket (OOP) medical costs have increased, and patients experience significant financial burden. Despite increasing interest in understanding and mitigating financial burdens, there is a relative paucity of data specific to HF. Here, we explore financial hardship in HF from the patient perspective, including estimated OOP costs for guideline-directed medical therapy for HF with reduced ejection fraction, hospitalizations, and total direct medical costs, as well as the consequences of high OOP costs. Studies estimate that high OOP costs are common in HF, and a large proportion are related to prescription drugs. Subsequently, the effects on patients can lead to worsening adherence, delayed care, and poor outcomes, leading to a financial toxicity spiral. Further, we summarize patients' cost preferences and outline future research that is needed to develop evidence-based solutions to reduce costs in HF.
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Affiliation(s)
- Alexander H Gunn
- Department of Medicine, Duke University School of Medicine, Durham, NC.
| | - Haider J Warraich
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
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MacDonald BJ, Virani SA, Zieroth S, Turgeon R. Heart Failure Management in 2023: A Pharmacotherapy- and Lifestyle-Focused Comparison of Current International Guidelines. CJC Open 2023; 5:629-640. [PMID: 37720183 PMCID: PMC10502425 DOI: 10.1016/j.cjco.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/17/2023] [Indexed: 09/19/2023] Open
Abstract
This review examines the pharmacotherapy and lifestyle recommendations of the most recent iterations of the Canadian Cardiovascular Society (CCS) / Canadian Heart Failure Society (CHFS), the European Society of Cardiology (ESC), and the American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Failure Society of America (HFSA) heart failure (HF) guidelines, which all have been updated in response to therapeutic developments across the spectrum of left ventricular ejection fraction. Identified areas of unanimity across these guidelines include the following: recommending quadruple therapy for patients with HF with reduced ejection fraction (HFrEF; although no guideline proposed an ideal sequence of initiation); intravenous iron administration for patients with HFrEF and iron deficiency; and sodium restriction for patients with HF. Recent evidence regarding the harms of HFrEF medication withdrawal in patients with HF with improved ejection fraction has prompted subsequent guidelines to recommend against withdrawal. Due to the lower quality of evidence, there are disagreements regarding management of HF with preserved ejection fraction and uncertainty regarding management of HF with mildly reduced ejection fraction. Practical guidance is provided to clinicians navigating these challenging areas. In addition to these clinically focused comparisons, we describe opportunities for guideline improvement and harmonization. Specifically, these include opportunities regarding HFrEF sequencing, the need for timely updates, shared decision-making, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework adoption, and the creation of recommendations where high-quality evidence is lacking. Although these guidelines have broad agreement, key areas of controversy remain that may be addressed by emerging evidence and changes in guideline methodology.
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Affiliation(s)
| | - Sean A. Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ricky Turgeon
- University of British Columbia, Vancouver, British Columbia, Canada
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Sukumar S, Wasfy JH, Januzzi JL, Peppercorn J, Chino F, Warraich HJ. Financial Toxicity of Medical Management of Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2043-2055. [PMID: 37197848 DOI: 10.1016/j.jacc.2023.03.402] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 05/19/2023]
Abstract
Optimal medical management of heart failure (HF) improves quality of life, decreases mortality, and decreases hospitalizations. Cost may contribute to suboptimal adherence to HF medications, especially angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors. Patients' experiences with HF medication cost include financial burden, financial strain, and financial toxicity. Although there has been research studying financial toxicity in patients with some chronic diseases, there are no validated tools for measuring financial toxicity of HF, and very few data on the subjective experiences of patients with HF and financial toxicity. Strategies to decrease HF-associated financial toxicity include making systemic changes to minimize cost sharing, optimizing shared decision-making, implementing policies to lower drug costs, broadening insurance coverage, and using financial navigation services and discount programs. Clinicians may also improve patient financial wellness through various strategies in routine clinical care. Future research is needed to study financial toxicity and associated patient experiences for HF.
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Affiliation(s)
- Smrithi Sukumar
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. https://twitter.com/SmrithiSukumar
| | - Jason H Wasfy
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James L Januzzi
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey Peppercorn
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fumiko Chino
- Memorial Sloan Kettering, New York, New York, USA
| | - Haider J Warraich
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, Massachusetts, USA.
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Rao BR, Akrobetu DJ, Dickert NW, Nguyen T, Davis JK, Campagna A, Mitchell AR, Sharma A, Speight CD, Barks MC, Farley S, Gutterman S, Santanam T, Ubel PA. Deciding Whether to Take Sacubitril/Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs. J Am Heart Assoc 2023; 12:e028278. [PMID: 36974764 PMCID: PMC10122884 DOI: 10.1161/jaha.122.028278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
Background Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorporated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient-cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postapproval period. Methods and Results We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, continue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. Conclusions Although cost conversations were somewhat common in patient-cardiologist encounters in which sacubitril/valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judgments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.
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Affiliation(s)
- Birju R. Rao
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | - Neal W. Dickert
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | | | | | - Ada Campagna
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
| | - Andrea R. Mitchell
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | - Anu Sharma
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
| | - Candace D. Speight
- Department of Medicine, Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | | | | | | | - Peter A. Ubel
- Duke University School of MedicineDurhamNCUSA
- Duke‐Margolis Center for Health PolicyDurhamNCUSA
- Duke University’s Fuqua School of BusinessDurhamNCUSA
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MacDonald BJ, Barry AR, Turgeon RD. Decisional Needs and Patient Treatment Preferences for Heart Failure Medications: A Scoping Review. CJC Open 2023; 5:136-147. [PMID: 36880079 PMCID: PMC9984897 DOI: 10.1016/j.cjco.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background Pharmacologic management of heart failure with reduced ejection fraction (HFrEF) involves several medications. Decision aids informed by patient decisional needs and treatment preferences could assist in making HFrEF medication choices; however, these are largely unknown. Methods We searched MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), without language restriction, for qualitative, quantitative, and mixed-method studies that included patients with HFrEF or clinicians providing HFrEF care, and reported data on decisional needs or treatment preferences applicable to HFrEF medications. We classified decisional needs using a modified version of the Ottawa Decision Support Framework (ODSF). Results From 3996 records, we included 16 reports describing 13 studies (n = 854). No study explicitly assessed ODSF decisional needs; however, 11 studies reported ODSF-classifiable data. Patients commonly reported having inadequate knowledge or information, and difficult decisional roles. No study systematically assessed treatment preferences, but 6 studies reported on attribute preferences. Reducing mortality and improving symptoms frequently were ranked as being important, whereas cost importance rankings varied, and adverse events generally were ranked as being less important. Conclusion This scoping review identified key decisional needs regarding HFrEF medications, notably inadequate knowledge or information, and difficult decisional roles, which can readily be addressed by decision aids. Future studies should systematically explore the full scope of ODSF-based decisional needs in patients with HFrEF, along with relative preferences among treatment attributes to further inform development of individualized decision aids.
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Affiliation(s)
- Blair J MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Johnson AE, Swabe GM, Addison D, Essien UR, Breathett K, Brewer LC, Mazimba S, Mohammed SF, Magnani JW. Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients. Circ Cardiovasc Qual Outcomes 2022; 15:e009179. [PMID: 35549378 PMCID: PMC9308667 DOI: 10.1161/circoutcomes.122.009179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.
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Affiliation(s)
- Amber E Johnson
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA; Division of Cardiology, University of Pittsburgh School of Medicine, PA
| | - Gretchen M Swabe
- Division of Cardiology, University of Pittsburgh School of Medicine, PA
| | - Daniel Addison
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University, OH
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, PA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh PA
| | | | - LaPrincess C Brewer
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN; Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN
| | - Sula Mazimba
- Division of Cardiovascular Medicine, Advanced Heart Failure and Transplant Center, University of Virginia, VA
| | | | - Jared W Magnani
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA; Division of Cardiology, University of Pittsburgh School of Medicine, PA
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8
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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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Ostrominski JW, Hirji S, Bhatt AS, Butler J, Fiuzat M, Fonarow GC, Heidenreich PA, Januzzi JL, Lam CSP, Maddox TM, O'Connor CM, Vaduganathan M. Cost and Value in Contemporary Heart Failure Clinical Guidance Documents. JACC. HEART FAILURE 2022; 10:1-11. [PMID: 34969491 DOI: 10.1016/j.jchf.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/26/2021] [Accepted: 08/13/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES This study sought to evaluate the frequency and nature of cost/value statements in contemporary heart failure (HF) clinical guidance documents (CGDs). BACKGROUND In an era of rising health care costs and expanding therapeutic options, there is an increasing need for formal consideration of cost and value in the development of HF CGDs. METHODS HF CGDs published by major professional cardiovascular organizations between January 2010 and February 2021 were reviewed for the inclusion of cost/value statements. RESULTS Overall, 33 documents were identified, including 5 (15%) appropriate use criteria, 7 (21%) clinical practice guidelines, and 21 (64%) expert consensus documents. Most CGDs (27 of 33; 82%) included at least 1 cost/value statement, and 20 (61%) CGDs included at least 1 cost/value-related citation. Most of these statements were found in expert consensus documents (77.7%). Three (9%) documents reported estimated costs of recommended interventions, but only 1 estimated out-of-pocket cost. Of 179 cost/value-related statements observed, 116 (64.8%) highlighted the economic impact of HF or HF-related care, 6 (3.4%) advocated for cost/value issues, 15 (8.4%) reported gaps in cost/value evidence, and 42 (23.5%) supported clinical guidance recommendations. Over time, patterns of inclusion of statements and citations of cost/value have been largely stable. CONCLUSIONS Although most contemporary HF CGDs contain at least 1 cost/value statement, most CGDs focus on the high economic impact of HF and its related care; explicit inclusion of cost/value to support clinical guidance recommendations remains infrequent. These results highlight key opportunities for the integration of formalized cost/value considerations in future HF-focused CGDs.
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Affiliation(s)
- John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ankeet S Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine in St Louis, St Louis, Missouri, USA; Healthcare Innovation Lab, BJC HealthCare/Washington University School of Medicine, St Louis, Missouri, USA
| | - Christopher M O'Connor
- Division of Cardiology, Duke University, Durham, North Carolina, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Cost-Utility Analysis of Sacubitril-Valsartan Compared with Enalapril Treatment in Patients with Acute Decompensated Heart Failure in Thailand. Clin Drug Investig 2021; 41:907-915. [PMID: 34533783 PMCID: PMC8446182 DOI: 10.1007/s40261-021-01079-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND Sacubitril-valsartan is effective in reducing the N-terminal pro-B-type natriuretic peptide level of hospitalized patients with acute decompensated heart failure, with a high acquisition cost compared with enalapril treatment. OBJECTIVE This study aimed to determine the cost utility of sacubitril-valsartan compared with enalapril for acute decompensated heart failure treatment. METHODS A Markov model was constructed to project the total costs, life-years, quality-adjusted life-years (QALYs) of early initiation, and a 2-month delay of sacubitril-valsartan treatment and enalapril treatment in hospitalized patients with acute decompensated heart failure over a lifetime horizon from a Thai healthcare system perspective. Clinical inputs were mainly derived from the PIONEER-HF and PARADIGM-HF trials, together with Thai epidemiological data. Cost data were based on the Thai population. All costs and outcomes were discounted at 3% annually. A series of sensitivity analyses were performed. RESULTS Compared with enalapril, sacubitril-valsartan incurred a higher total cost per year (THB 42,994 [US$1367.48] vs THB 19,787 [US$629.37]), and it gained more QALYs (4.969 vs 4.755). The incremental cost-effectiveness ratio was THB 108,508/QALY (US$3451.26/QALY). Early initiation of sacubitril-valsartan treatment was more cost effective than delayed treatment. Sensitivity analyses revealed that at a level of willingness to pay of THB 160,000/QALY (US$5089/QALY), sacubitril-valsartan was a cost-effective strategy of about 60%. CONCLUSIONS Sacubitril-valsartan is cost effective in patients with acute decompensated heart failure. However, the results are highly dependent on the long-term cardiovascular mortality, and they are applicable only to Thailand or countries with a similarly structured healthcare system. Long-term registries should be pursued to decrease the uncertainty around long-term mortality.
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Gagné M, Lam Shin Cheung J, Kouri A, FitzGerald JM, O'Byrne PM, Boulet LP, Grill A, Gupta S. A patient decision aid for mild asthma: Navigating a new asthma treatment paradigm. Respir Med 2021; 201:106568. [PMID: 34429221 DOI: 10.1016/j.rmed.2021.106568] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/26/2021] [Accepted: 08/06/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION In mild asthma, as-needed budesonide-formoterol offers similar protection from severe exacerbations as daily inhaled corticosteroids (ICS), with lower ICS exposure but slightly increased symptoms. We sought to develop an electronic decision aid to guide discussions about the pros and cons of these first-line options, while identifying and integrating user preferences. METHODS Following International Patient Decision Aid Standards, we created a mild asthma decision aid prototype comparing convenience, clinical outcomes, cumulative ICS dose exposure, costs, and side-effects of each option. After face validation, the prototype was iteratively adapted through rapid-cycle development. Each cycle consisted of a patient focus group and a primary care physician interview. We made user preference-based improvements after each round, until reaching a pre-set stopping criterion (no new critical issues identified). We then performed a summative qualitative content analysis. RESULTS Over 5 cycles, we recruited 21 asthma patients (12/21 women, 10/21 ≥ 60 years old) and 5 physicians. Serial changes included simplification and reduction of text and reading level, inclusion of an ICS "myths" section and elaboration of patient-friendly infographics for numerical comparisons. User preferences fell within Content, Format, and tool use Process themes. In response to decision-making preferences, we created a complementary one-page conversation aid for patient-provider use at the point-of-care. CONCLUSIONS We present preference-based electronic patient decision and conversation aids for treatment of mild asthma. Our user preference analyses offer useful insights for development of such tools in other chronic diseases. These tools now require integration into point-of-care workflows for measurement of real-world uptake and impact.
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Affiliation(s)
- Myriam Gagné
- Division of Respirology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
| | | | - Andrew Kouri
- Division of Respirology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
| | - J Mark FitzGerald
- Centre for Lung Health, Vancouver Coastal Health Research Institute, Vancouver, BC Canada; University of British Columbia, Vancouver, BC Canada.
| | - Paul M O'Byrne
- Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada; Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada; Faculté de Médecine, Université Laval, Québec, QC, Canada.
| | - Allan Grill
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Samir Gupta
- Division of Respirology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
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Warraich HJ, Ali HJR, Nasir K. Financial Toxicity With Cardiovascular Disease Management. Circ Cardiovasc Qual Outcomes 2020; 13:e007449. [DOI: 10.1161/circoutcomes.120.007449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Haider J. Warraich
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (H.J.W.)
- Harvard Medical School, Boston, MA (H.J.W.)
- Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA (H.J.W.)
| | - Hyeon Ju R. Ali
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (H.J.R.A., K.N.)
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX (H.J.R.A., K.N.)
- Center for Outcomes Research, Houston Methodist, Houston, TX (K.N.)
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, TX (K.N.)
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